1
|
Hsu TA, Huang JF, Kuo LW, Cheng CT, Kuo YC, Liao CH, Hsieh CH, Fu CY. Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma? J Endovasc Ther 2024; 31:428-437. [PMID: 36214460 DOI: 10.1177/15266028221128200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization. MATERIALS AND METHODS From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups. RESULTS Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001). CONCLUSION An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI. CLINICAL IMPACT More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.
Collapse
Affiliation(s)
- Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| |
Collapse
|
2
|
Golestani S, Dubose JJ, Efird J, Teixeira PG, Cardenas TC, Trust MD, Ali S, Aydelotte J, Bradford J, Brown CV. Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury. J Am Coll Surg 2024; 238:1099-1104. [PMID: 38407302 DOI: 10.1097/xcs.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.
Collapse
Affiliation(s)
- Simin Golestani
- From the Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Wang Y, Wang B, Qiu C. TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm: Case report and systematic review. Vascular 2024:17085381241254427. [PMID: 38739928 DOI: 10.1177/17085381241254427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Blunt thoracic aortic injuries (BTAIs) involving the aortic arch are a challenging condition. Thoracic endovascular aortic repair (TEVAR) with fenestration, which expands the proximal landing zone, is able to exclude the injury while preserving blood flow in supra-aortic branches. METHODS Here we report a case of TEVAR with fenestrations of all supra-aortic branches for traumatic aortic pseudoaneurysm and perform a systematic review. RESULTS A 24-year-old man suffering a blunt thoracic injury and a left femoral fracture was sent to our hospital. A pseudoaneurysm was found in the aortic arch between the brachiocephalic artery and the left common carotid artery. The patient underwent emergent TEVAR with fenestrations of all supra-aortic branches, which excluded the pseudoaneurysm and preserved the patency of all branches. The orthopedic team then treated the femoral fracture. The patient's recovery was unremarkable. We performed a systematic review on TEVAR with fenestrations for BTAI. Six patients (75%) received TEVAR with single fenestration, 1 patient (12.5%) received TEVAR with two fenestrations, and 1 patient (12.5%) had fenestrations of all supra-aortic branches. Except one patient died in the perioperative, other patients survived without stent-related complications in the short-term follow-up. CONCLUSIONS TEVAR with fenestration is feasible for treating BTAI involving the aortic arch in selected patients.
Collapse
Affiliation(s)
- Yashi Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
4
|
De Freitas S, Joyce D, Yang Y, Dunphy K, Walsh S, Fatima J. Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury. Ann Vasc Surg 2024; 98:220-227. [PMID: 37806657 DOI: 10.1016/j.avsg.2023.07.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/16/2023] [Accepted: 07/21/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. METHODS A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. RESULTS Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). CONCLUSIONS Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.
Collapse
Affiliation(s)
- Simon De Freitas
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC.
| | - Doireann Joyce
- Department of Vascular Surgery, Galway University Hospital, Galway, Republic of Ireland
| | - Yang Yang
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| | - Kaitlyn Dunphy
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| | - Stewart Walsh
- Department of Vascular Surgery, Galway University Hospital, Galway, Republic of Ireland
| | - Javairiah Fatima
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| |
Collapse
|
5
|
Gang Q, Lun Y, Pang L, Li X, Hou B, Xin S, Zhang J. Traumatic Aortic Dissection as a Unique Clinical Entity: A Single-Center Retrospective Study. J Clin Med 2023; 12:7535. [PMID: 38137605 PMCID: PMC10744057 DOI: 10.3390/jcm12247535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND This study aimed to compare the clinical characteristics, treatment approaches, and outcomes of the Stanford Type B traumatic aortic dissection (TAD) with non-traumatic aortic dissection (NTAD), and assess better management for TAD. METHODS We retrospectively analyzed patients who underwent thoracic endovascular aortic repair for Stanford type B aortic dissection at The First Hospital of China Medical University between 2014 and 2022. The patients were divided into TAD and NTAD groups based on whether they had a history of acute trauma. This study ultimately included 65 patients with TAD and 288 with NTAD. We assessed and compared the baseline characteristics, laboratory indicators, imaging features, surgical procedures, and follow-up results between the groups. RESULTS The TAD group was younger compared to the NTAD group (50.00 [IQR40.00-59.00] vs. 55.00 [IQR 47.00-61.00] years, p = 0.020). A lower percentage of the TAD group had a history of hypertension (20% vs. 71.18%, p < 0.001). The length of aortic dissection was shorter in the TAD group compared to the NTAD group (30.00 [IQR 22.00-40.00] vs. 344.00 [IQR 237.25-400.00] mm, p < 0.001). All patients with TAD underwent TEVAR following the same strategy as NTAD. The mean preoperative duration was 7.00 (IQR 2.00-14.00) days in the TAD group and 11.00 (IQR 8.00-15.00) days in the NTAD group (p < 0.001). TAD showed fewer complications after TEVAR in mid-to-long-term follow-up. CONCLUSIONS TAD is distinct from NTAD. TAD typically presents with more localized lesions than NTAD, and the patients experience a shorter preoperative duration and a better mid-to-long-term outcome.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Jian Zhang
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital of China Medical University, Shenyang 110001, China; (Q.G.); (Y.L.); (L.P.); (X.L.); (B.H.); (S.X.)
| |
Collapse
|
6
|
Cheraghali R, Kharazm P, Afghani R, Amanian D, Hajihoseini N. Hemoptysis as a rare manifestation of missed blunt thoracic aorta injury, a case report. Int J Surg Case Rep 2023; 112:108918. [PMID: 37856967 PMCID: PMC10667740 DOI: 10.1016/j.ijscr.2023.108918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Blunt thoracic aorta injury is one of the most fatal injuries in multiple trauma patients and most of these injuries lead to death at the scene. Some patients remain undiagnosed because of the lack of specific symptoms for these injuries. Hemoptysis as a presentation of a neglected blunt aortic trauma is a very rare condition. In this study, we present a case with a 7-month delay in presentation and diagnosis. CASE PRESENTATION A 49-year-old man with a complaint of intermittent hemoptysis was presented to the clinic. He had a history of chest trauma following falling 7 months ago. His physical examination was unremarkable. On Computed Tomography Angiography (CTA) pseudoaneurysm of the descending aorta was detected and the patient was treated urgently with a stent graft. CLINICAL DISCUSSION Blunt thoracic aorta injury may occur following deceleration traumas. Descending aorta is the most involved segment but other segments may be involved as well. Bleeding can be stopped by tamponading the aorta with its overlying pleura. In some cases, pseudoaneurysms are formed and may remain undiagnosed for a long time after index trauma. CTA is the most useful diagnostic study and when the diagnosis is made, urgent treatment is mandatory. Although endovascular repair has significantly lower mortality and morbidity, open surgical repair may be inevitable in some cases. CONCLUSION Thoracic aorta injury should be suspected in any patient with severe deceleration trauma and CTA should be used promptly for the diagnosis and treatment of these potentially fatal injuries.
Collapse
Affiliation(s)
- Roozbeh Cheraghali
- Clinical Research Development Center, 5 Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Pezhman Kharazm
- Clinical Research Development Center, 5 Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Reza Afghani
- Clinical Research Development Center, 5 Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran.
| | - Dayan Amanian
- Clinical Research Development Center, 5 Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
| | - Navid Hajihoseini
- Clinical Research Development Center, 5 Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
| |
Collapse
|
7
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
8
|
Stonko DP, Edwards J, Abdou H, Treffalls RN, Walker P, DeMartino RR, Mendes BC, Hicks CW, Morrison JJ. Thoracic Endovascular Aortic RepairAcutely Augments Left Ventricular Biomechanics in An Animal Model: A Mechanism for Postoperative Heart Failure and Hypertension. Ann Vasc Surg 2023; 97:18-26. [PMID: 37068623 PMCID: PMC10754260 DOI: 10.1016/j.avsg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 04/05/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Thoracic aortic stent grafts are thought to decrease aortic compliance and may contribute to hypertension and heart failure after thoracic endovascular aortic repair (TEVAR). Left ventricular (LV) biomechanics immediately after TEVAR, however, have not been quantified. Pressure-volume (PV) loop analysis provides gold-standard LV functional information. The aim of this study is to use an LV PV loop catheter and analysis to characterize the LV biomechanics before and acutely after TEVAR. METHODS Anesthetized Yorkshire swine (N = 6) were percutaneously instrumented with an LV PV loop catheter. A 20 mm × 10 cm stent graft was deployed distal to the left subclavian via the femoral artery under fluoroscopy. Cardiac biomechanics were assessed before and after TEVAR. As a sensitivity analysis, inferior vena cava occlusion with PV loop assessment was performed pre and post-TEVAR in 1 animal to obtain preload and afterload-independent end-systolic and end-diastolic PV relationships (ESPVR and EDPVR). RESULTS All animals underwent successful instrumentation and TEVAR. Post-TEVAR, all 6 animals had higher mean LV ESP (106 vs. 118 mm Hg, P = 0.04), with no change in the EDPVR. inferior vena cava occlusion also moved the ESPVR curve upward and leftward, indicating increased LV work per unit time. There was no augmentation of EDPVR following TEVAR (P > 0.05). Postmortem exams in all animals revealed appropriate stent placement and no technical complications. CONCLUSIONS TEVAR was associated with an acute increase in LV end-systolic pressure and shift in the ESPVR, indicating increased ventricular work. This data provides potential mechanistic insights into the development of post-TEVAR hypertension and heart failure. Future stent graft innovation should focus on minimizing the changes in cardiac physiology.
Collapse
Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | | | - Patrick Walker
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | | | - Bernardo C Mendes
- Divison of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | | |
Collapse
|
9
|
Lee H, Kwon H, Kim CW, Hwangbo L. [Intervention for Chest Trauma and Large Vessel Injury]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:809-823. [PMID: 37559800 PMCID: PMC10407064 DOI: 10.3348/jksr.2023.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/23/2023] [Accepted: 06/20/2023] [Indexed: 08/11/2023]
Abstract
Trauma is an injury to the body that involves multiple anatomical and pathophysiological changes caused by forces acting from outside the body. The number of patients with trauma is increasing as our society becomes more sophisticated. The importance and demand of traumatology are growing due to the development and spread of treatment and diagnostic technologies. In particular, damage to the large blood vessels of the chest can be life-threatening, and the sequelae are often severe; therefore, diagnostic and therapeutic methods are becoming increasingly important. Trauma to non-aortic vessels of the thorax and aorta results in varying degrees of physical damage depending on the mechanism of the accident and anatomical damage involved. The main damage is hemorrhage from non-aortic vessels of the thorax and aorta, accompanied by hemodynamic instability and coagulation disorders, which can be life-threatening. Immediate diagnosis and rapid therapeutic access can often improve the prognosis. The treatment of trauma can be surgical or interventional, depending on the patient's condition. Among them, interventional procedures are increasingly gaining popularity owing to their convenience, rapidity, and high therapeutic effectiveness, with increasing use in more trauma centers worldwide. Typical interventional procedures for patients with thoracic trauma include embolization for non-aortic injuries and thoracic endovascular aortic repair for aortic injuries. These procedures have many advantages over surgical treatments, such as fewer internal or surgical side effects, and can be performed more quickly than surgical procedures, contributing to improved outcomes for patients with trauma.
Collapse
|
10
|
Mazzaccaro D, Righini P, Fancoli F, Giannetta M, Modafferi A, Malacrida G, Nano G. Blunt Thoracic Aortic Injury. J Clin Med 2023; 12:jcm12082903. [PMID: 37109240 PMCID: PMC10142366 DOI: 10.3390/jcm12082903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Blunt thoracic aortic injury (BTAI) is a potentially fatal condition that needs prompt recognition and expedited management. Clinical manifestations of BTAI are not straight forwarding and may be misdiagnosed. The grade of aortic injury is an important determinant of perioperative mortality and morbidity, as well as the indication of treatment, along with the presence of concomitant lesions of other involved organs. The mainstay of treatment nowadays for hemodynamically stable patients who survive the trauma scene is represented by delayed endovascular repair whenever anatomically and clinically feasible. Endovascular repair, in fact, is burdened by lower perioperative mortality and morbidity rates if compared to open surgical repair, but concerns remain about the need for long-term surveillance and radiation exposure in patients who are at a younger age than patients treated for the aneurysmal disease. The aim of the paper is to provide an update on the diagnostic modalities and strategies of treatment for patients affected by BTAI.
Collapse
Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Fabiana Fancoli
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Matteo Giannetta
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Alfredo Modafferi
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Malacrida
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Nano
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
| |
Collapse
|
11
|
De Freitas S, Fatima J. Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients Using Data from the National Trauma Data Bank: Letter to the Editor. Ann Vasc Surg 2023; 91:298-299. [PMID: 36574832 DOI: 10.1016/j.avsg.2022.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Simon De Freitas
- MedStar Georgetown Vascular Surgery, MedStar Health, Washington, DC
| | - Javairiah Fatima
- MedStar Georgetown Vascular Surgery, MedStar Health, Washington, DC
| |
Collapse
|
12
|
Fitzpatrick ER. Evidence-Based Pearls. Crit Care Nurs Clin North Am 2023; 35:129-144. [PMID: 37127370 DOI: 10.1016/j.cnc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
The challenge in caring for patients who sustain traumatic chest injuries centers on their complex needs from high acuity and the potential for multisystem effects and complications. Hemorrhage and respiratory compromise are common sequela of thoracic trauma. Patients must be resuscitated and their injuries managed with the primary goals of restoring cardiopulmonary structural integrity and preventing complications. There are evolving strategies for the management of the thoracic trauma victim including damage control resuscitation and surgery, endovascular repairs, and assessments implementing severity scores to aid in planning interventions.
Collapse
|
13
|
Pollock GA, Lo J, Chou H, Kissen MS, Kim M, Zhang V, Betz A, Perlman R. Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review. Br J Anaesth 2023; 130:e80-e91. [PMID: 36096943 DOI: 10.1016/j.bja.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023] Open
Abstract
Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.
Collapse
Affiliation(s)
- Gabriel A Pollock
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jessie Lo
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henry Chou
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael S Kissen
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle Kim
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vida Zhang
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Betz
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Perlman
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
14
|
Yau PO, Lewis E, Shah A, Stone ME, McNelis J, Rivera A. Blunt traumatic aortic injury in the elderly population. J Vasc Surg 2023; 77:47-55.e1. [PMID: 35948245 DOI: 10.1016/j.jvs.2022.07.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.
Collapse
Affiliation(s)
- Patricia O Yau
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY.
| | - Erin Lewis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Amit Shah
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Melvin E Stone
- Department of Surgery, Kings County Hospital, State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - John McNelis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Aksim Rivera
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| |
Collapse
|
15
|
Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2023; 94:113-116. [PMID: 35999667 DOI: 10.1097/ta.0000000000003759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
16
|
Sun J, Ren K, Zhang L, Xue C, Duan W, Liu J, Cong R. Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis. J Cardiothorac Surg 2022; 17:335. [PMID: 36564841 PMCID: PMC9783465 DOI: 10.1186/s13019-022-02094-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Approximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment. This study analyzed and reported the treatment strategy of a single center for BTAI in the last 10 years and the early and middle clinical results. METHODS This retrospective study included patients diagnosed with BTAI at Xijing Hospital from 2013 to 2022. All inpatients with BTAI aged ≥ 18 years were included in this study. The clinical data, imaging findings, and follow-up results were retrospectively collected and analyzed. The Kaplan-Meier curve and multivariate logistic regression were used to compare survivors and nonsurvivors. RESULTS A total of 72 patients (57% men) were diagnosed with BTAI, with a mean age of 54.2 ± 9.1 years. The injury severity score was 24.3 ± 18, with Grade I BTAI1 (1.4%), Grade II 17 (23.6%), Grade III 52 (72.2%), and Grade IV 2 (2.8%) aortic injuries. Traffic accidents were the main cause of BTAI in 32 patients (44.4%). Most patients had trauma, 37 had rib fractures (51.4%), Sixty patients (83.3%) underwent thoracic endovascular aortic repair (TEVAR) surgery, eight (11.1%) underwent conservative treatment, and only four (5.6%) underwent open surgery. The overall hospitalization mortality was 12.5%. In multivariate logistic regression, elevated creatinine levels (P = 0.041) and high Glasgow coma scale (GCS) score (P = 0.004) were the predictors of hospital mortality. The median follow-up period was 57 (28-87) months. During the follow-up period, all-cause mortality was 5.6% and no aortic-related deaths were reported. Three patients (4.2%) needed secondary surgery and two of them underwent endovascular repair. CONCLUSION Although TEVAR surgery may be associated with intra- or postoperative dissection rupture or serious complications in the treatment of Grade III BTAI, the incidence rate was only 8.9%. Nevertheless, TEVAR surgery remains a safe and feasible approach for the treatment of Grade II or III BTAI, and surgical treatment should be considered first,. A high GCS score and elevated creatinine levels in the emergency department were closely associated with hospital mortality. Younger patients need long-term follow-up after TEVAR.
Collapse
Affiliation(s)
- Jingwei Sun
- grid.508540.c0000 0004 4914 235XXi’an Medical University, Xi’an, China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Kai Ren
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Liyun Zhang
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Chao Xue
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Weixun Duan
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, The First Affiliated Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Jincheng Liu
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, The First Affiliated Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Ren Cong
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| |
Collapse
|
17
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 296] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
18
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
19
|
Bae M, Jeon CH. Optimal Sizing of Aortic Stent Graft for Blunt Thoracic Aortic Injury Considering Hypotension-Related Decrease in Aortic Diameter. J Endovasc Ther 2022:15266028221134894. [PMID: 36342200 DOI: 10.1177/15266028221134894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To evaluate the optimal sizing of an aortic stent graft in patients with blunt thoracic aortic injury (BTAI), considering the decrease in diameter in hypovolemic status. MATERIALS AND METHODS From 2014 to 2020, 25 patients who underwent thoracic endovascular aortic repair (TEVAR) for BTAI were included. Hemodynamic parameters in the emergency room (ER) and just before the main procedure (MP) were collected. The aortic sizes were measured during initial computed tomography (CT) on arrival in the ER, aortography (AG) during TEVAR, and final CT in the outpatient clinic. The appropriateness of the inserted stent graft size was investigated. RESULTS The mean values of the final CT/initial CT and final CT/initial AG (proximal descending thoracic aorta [pDTA]) were 113% and 105%, respectively. The final CT/initial CT (pDTA; 122.2% vs 108.8%, p=0.01) and final CT/initial AG (pDTA; 113.4% vs 102.1%, p<0.01) were significantly higher in patients with systolic blood pressure (SBP; MP) ≤90 mm Hg. The final CT/initial CT (pDTA; 120.4% vs 109.0%, p=0.03) and final CT/initial AG (pDTA; 111.4% vs 102.6%, p=0.01) were significantly higher in patients with mean blood pressure (MBP; MP) ≤70 mm Hg. On an average, the inserted stent grafts were oversized by 130% on initial AG. Based on the final CT scan, the inserted stent graft was as large as 122%. CONCLUSION In the case of hemodynamic instability with SBP (MP) ≤90 mm Hg or MBP (MP) ≤70 mm Hg, despite adequate resuscitation, an oversized TEVAR stent graft of 130% can reduce the occurrence of endoleak and is sufficiently safe. CLINICAL IMPACT Despite sufficient resuscitation, the aorta size measured during TEVAR in patients with hemodynamic instability with systolic BP <90 mmHg and mean BP <70 mmHg may be reduced by more than 15% compared to that in the normal state. In this study, the mean size of the stent grafts were oversized by 130% on initial aortography, but were oversized by 122% based on final CT. When the stent graft was oversized by 130% in TEVAR for hemodynamic unstable patient with BTAI, the patient reached the proper oversizing subsequent to hemodynamic recovery.
Collapse
Affiliation(s)
- Miju Bae
- Department of Thoracic & Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Chang Ho Jeon
- Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
20
|
Abdou H, Edwards J, Stonko D, Elansary N, Ottochian M, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting. Ann Vasc Surg 2022; 87:522-528. [PMID: 35760265 DOI: 10.1016/j.avsg.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin. RESULTS 3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSION These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.
Collapse
Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| |
Collapse
|
21
|
Jinadasa SP, Mueller AL, Apffel A, Cave B, DuBose JJ, Scalea TM, Kundi R. Close surveillance imaging is unnecessary for patients with grade I blunt thoracic aortic injury. Am J Surg 2022; 224:1324-1328. [PMID: 35728986 DOI: 10.1016/j.amjsurg.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND No evidence-based recommendations exist for imaging surveillance of grade I blunt thoracic aortic injuries (BTAI). We aimed to evaluate the natural history of these injuries to provide guidance for follow-up imaging. METHODS Patients that presented to our trauma center from 2008 to 2021 with grade I BTAI were retrospectively evaluated. CT angiography images were assessed for initial injury grade and subsequent stability, improvement, worsening, or resolution. RESULTS Of 83 patients who had grade I injuries and repeat imaging, 57.8% had complete resolution, 20.5% had improvement, and 18.1% had stability of their injury. Only seven patients (8.4%) demonstrated worsening of their injury. Six patients had eventual resolution and one underwent endovascular repair that would not have been performed under current practice patterns. CONCLUSIONS Since grade I injuries do not worsen to require later surgical intervention, early surveillance imaging is not necessary and further imaging may not be necessary at all.
Collapse
Affiliation(s)
- Sayuri P Jinadasa
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Annie Apffel
- University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA.
| | - Brandon Cave
- University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| |
Collapse
|
22
|
O'Banion LA, Dirks RC, Siada SS, Dubose JJ, Inaba K, Byerly S, Rajani RR, Morrison JJ, Lucero L, Magee GA. Risk factors for stroke in penetrating carotid trauma-An analysis from the PROOVIT Registry. J Trauma Acute Care Surg 2022; 92:717-722. [PMID: 34991129 DOI: 10.1097/ta.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Penetrating carotid injuries are associated with an up to 20% risk of stroke. This study evaluated patients in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial, with the aim of determining factors associated with stroke and stroke or death. METHODS Penetrating extracranial carotid injuries in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial registry from 2012 to 2020 were queried. Isolated external carotid injuries were excluded. Patients with documented postinjury in-hospital stroke were compared with those without. Significant predictors (p < 0.1) for stroke and stroke or death on univariate analysis were included in multivariate analyses. RESULTS One hundred two patients from 17 institutions were included. Mean age was 35 ± 18 years, and 80% were male. Average Glasgow Coma Scale (GCS) score on presentation was 9 ± 5, with an Injury Severity Score [ISS] of 22 ± 13. Operative management occurred in 51% of patients who were significantly more hypotensive (systolic blood pressure: 109 vs. 131 mm Hg; p = 0.015) with a lower initial pH (7.17 vs. 7.31; p = 0.001) and presented with hard signs of vascular injury (74% vs. 26%; p < 0.001). Overall stroke rate was 17% (23% operative vs. 10% nonoperative, p = 0.076). Rate of stroke or death was 27% (64% operative and 36% nonoperative). On multivariate analysis, lower GCS (p = 0.05) and completion angiography (p = 0.04) were associated with stroke. Likewise lower GCS (p = 0.015) and ISS (p = 0.04) were associated with stroke or death. CONCLUSION Penetrating carotid trauma undergoing operative management had a stroke rate of 23%. Low GCS on arrival and need for completion angiography are independently associated with postinjury in-hospital stroke, whereas low GCS on arrival and ISS were associated with stroke or death. The ideal treatment strategy remains elusive, thus a dedicated multicenter study may help to achieve higher fidelity data on this rare but devastating injury. LEVEL OF EVIDENCE Prognostic and Epidemiological, Level III.
Collapse
Affiliation(s)
- Leigh Ann O'Banion
- From the Division of Vascular Surgery, Department of Surgery (L.A.OB., R.C.D., S.S.S., L.L.), University of California San Francisco-Fresno, Fresno, California; Division of Trauma and Critical Care (J.J.D., J.J.M.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; Division of Vascular and Endovascular Surgery and Division of Trauma and Critical Care, Department of Surgery (K.I., G.A.M.), University of Southern California, Los Angeles, California; Division of Trauma and Critical Care, Department of Surgery (S.B.), University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida; and Division of Vascular Surgery and Endovascular Therapy, Department of Surgery (R.R.R.), Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Scalea TM. Caring for vascular injuries: Training more vascular specialists may not be the answer. J Trauma Acute Care Surg 2022; 92:760-761. [PMID: 35045058 DOI: 10.1097/ta.0000000000003526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury. Ann Vasc Surg 2022; 84:195-200. [PMID: 35247536 DOI: 10.1016/j.avsg.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.
Collapse
|
25
|
Herrold JA, Adnan S, Romagnoli A, Madurska MJ, Betzold R, DuBose J, Scalea T, Morrison JJ. Certification in endovascular hemostasis for trauma surgeons: Possible and practical? J Trauma Acute Care Surg 2021; 91:775-780. [PMID: 34108419 DOI: 10.1097/ta.0000000000003234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular hemostasis is commonplace with many practitioners providing services. Accruing sufficient experience during training could allow acute care surgeons (ACSs) to expand their practice. We quantified case load and training opportunities at our center, where dedicated dual-trained ACS/vascular surgery faculty perform these cases. Our aim was to assess whether ACS fellows could obtain sufficient experience in 6 months of their fellowship in order to certify in these techniques, per the requirements of other specialties. METHODS We performed a retrospective case series where we reviewed 6 years (2013-2018) of endovascular activity at an academic, level I trauma center quantifying arterial access, angiography, embolization, stent and stent graft placement, and IVC filter procedures. This was compared with the certification requirements for interventional radiology, vascular surgery, cardiothoracic surgery, and interventional cardiology. RESULTS Between 2013 and 2018, 1,179 patients with a mean ± SD Injury Severity Score of 22.47 ± 13.24, underwent 4960 procedures. Annual rates per procedure, expressed as median (interquartile range), were arterial access 193.5 (181-195.5), diagnostic angiography 352 (321.5-364.5), embolization 90.5 (89.25-93.25), stent placement 24 (13.5-29.25), and IVC filter procedures 16.5 (10-23.75). Our 6-month case volume exceeded or was within 85% of the required number of cases for vascular surgery and interventional radiology training, with the exception of stent-graft deployment for both specialties, and therapeutic procedures for vascular surgery. CONCLUSION The case volume at a large trauma center with a dedicated endovascular trauma service is sufficient to satisfy the case requirements for endovascular certification. Our trainees are already acquiring this experience informally. An endovascular trauma curriculum should now be developed to support certification within ACS fellowship training.
Collapse
|
26
|
Arbabi CN, DuBose J, Charlton-Ouw K, Starnes BW, Saqib N, Quiroga E, Miller C, Azizzadeh A. Outcomes and practice patterns of medical management of blunt thoracic aortic injury from the Aortic Trauma Foundation global registry. J Vasc Surg 2021; 75:625-631. [PMID: 34560220 DOI: 10.1016/j.jvs.2021.08.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/25/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical management (MM) for BTAI. We hypothesized from the results of several previously reported studies, that patients with a minimal aortic injury (BTAI grades 1 and 2) could safely be treated with definitive MM alone. METHODS The Aortic Trauma Foundation international prospective multicenter registry was used to examine the demographics, injury characteristics, management, and outcomes of patients with BTAI. We analyzed a subset of patients for whom MM was initiated as definitive therapy. RESULTS From November 2016 to April 2020, 432 patients (median age, 41 years; 76% male; median injury severity score, 34) with BTAI (Society for Vascular Surgery grade 1, 23.6%; grade 2, 14.4%; grade 3, 51.2%; grade 4, 10.9%) were evaluated. Of the 432 patients, 245 (57%) had received MM in the initial period and 114 (26.4%) had received MM as the planned definitive therapy (grade 1, 59.6%; grade 2, 23.7%; grade 3, 15.8%; grade 4, 0.9%). The most common mechanism of BTAI was a motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was used for 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) the most common agent used. Treatments were targeted to a goal systolic blood pressure for 83.3%, most often to a target goal systolic blood pressure <120 mm Hg (66.3%). The MM goals based on blood pressure control were attained in 64.0% (73 of 114). Twelve patients (10.5%; grade 1, 1; grade 2, 0; grade 3, 10; grade 4, 1) had required subsequent intervention after MM. Eleven patients (9.6%) had undergone thoracic endovascular aortic repair and one (0.9%) had required open repair for a grade 4 injury. The overall in-hospital mortality for patients selected for definitive MM was 7.9%. No aortic-related deaths had occurred in the patients receiving definitive MM. CONCLUSIONS Approximately one in four patients with BTAI will receive MM as definitive therapy. The variation in the pharmacologic therapies used is considerable. MM for patients with minimal aortic injury (BTAI grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support the use of definitive MM for grade 2 BTAI.
Collapse
Affiliation(s)
- Cassra N Arbabi
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Joseph DuBose
- Division of Vascular Surgery, Department of Surgery, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Md
| | - Kristofer Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Naveed Saqib
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Charles Miller
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - Ali Azizzadeh
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
| |
Collapse
|
27
|
Erdoğan KE, Beşler MS, Canyiğit M, Hıdıroğlu M. Endovascular repair of a distal thoracic aortic transection in association with traumatic burst fracture. Indian J Thorac Cardiovasc Surg 2021; 37:554-557. [PMID: 34511763 DOI: 10.1007/s12055-021-01138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/25/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
We present an endovascular repair of aortic transection at distal thoracic level due to traumatic burst fracture. The association of blunt aortic transections and thoracic burst fractures is very rare. Contemporary preferred treatment approach is endovascular aortic repair, because of low mortality rates. The aortic repair procedure should be performed before spinal stabilization surgery. In this case report, we present a 49-year-old male patient with blunt traumatic descending thoracic aortic transection, treated by endovascular aortic repair. In conclusion, the emergent endovascular repair is a preferable method to treat the traumatic distal thoracic aortic transection.
Collapse
Affiliation(s)
| | | | - Murat Canyiğit
- Department of Radiology, Ankara Yıldırım Beyazıt University Faculty of Medicine, Ankara, Turkey
| | - Mete Hıdıroğlu
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| |
Collapse
|
28
|
Abdou H, Elansary NN, Darko L, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. Postoperative complications of endovascular blunt thoracic aortic injury repair. Trauma Surg Acute Care Open 2021; 6:e000678. [PMID: 34337157 PMCID: PMC8286787 DOI: 10.1136/tsaco-2021-000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) has become the standard of care for thoracic aortic aneurysms and increasingly for blunt thoracic aortic injury (BTAI). Postoperative complications, including spinal cord ischemia and paraplegia, have been shown to be less common with elective TEVAR than with open thoracic or thoracoabdominal repair. Although small cohort studies exist, the postoperative complications of endovascular repair of traumatic aortic injury have not been described through large data set analysis. Methods A retrospective cohort analysis was performed of the American College of Surgeons Trauma Quality Improvement Program registry spanning from 2007 to 2017. All patients with BTAI who underwent TEVAR, as indicated by the Abbreviated Injury Scale or the International Classification of Diseases (ICD-9 or ICD-10), were included. Categorical data were presented as proportions and continuous data as mean and SD. OR was calculated for each postoperative complication. Results 2990 patients were identified as having undergone TEVAR for BTAI. The postoperative incidence of stroke was 2.8% (83), and 4.7% (140) of patients suffered acute kidney injury or renal failure. The incidence of spinal cord ischemia was 1.9% (58), whereas 0.2% (7) of patients suffered complete paraplegia. Renal events and stroke were found to occur significantly more frequently in those undergoing TEVAR (OR 1.758, 1.449–2.134 and OR 2.489, 1.917–3.232, respectively). Notably, there was no difference between TEVAR and non-operative BTAI incidences of spinal cord ischemia or paraplegia (OR 1.061, 0.799–1.409 and OR 1.698, 0.728–3.961, respectively). Discussion Postoperative intensive care unit care of patients after BTAI has historically focused on awareness of spinal cord ischemia. Our analysis suggests that after endovascular repair of blunt aortic trauma, care should involve vigilance primarily against postoperative cerebrovascular and renal events. Further study is warranted to develop guidelines for the intensivist managing patients after TEVAR for BTAI. Level of evidence Level III.
Collapse
Affiliation(s)
- Hossam Abdou
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA.,Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Noha N Elansary
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Louisa Darko
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Joseph J DuBose
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Thomas M Scalea
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | | | - Rishi Kundi
- Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| |
Collapse
|
29
|
Ma DS, Jeon YB. Single-Center Clinical Analysis of Traumatic Thoracic Aortic Injuries: A Retrospective Observational Study. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2021.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
30
|
Topcu AC, Ozeren-Topcu K, Bolukcu A, Sahin S, Seyhan AU, Kayacioglu I. Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 8:163-168. [PMID: 33761566 PMCID: PMC8043807 DOI: 10.1055/s-0040-1715608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center. METHODS Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls. RESULTS A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16-80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4-115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention. CONCLUSION Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.
Collapse
Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kamile Ozeren-Topcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bolukcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sinan Sahin
- Department of Radiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Avni U Seyhan
- Department of Emergency Medicine, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Ilyas Kayacioglu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
31
|
DuBose JJ, Charlton-Ouw K, Starnes B, Saqib N, Quiroga E, Morrison J, Gewertz B, Azizzadeh A. Do patients with minimal blunt thoracic aortic injury require thoracic endovascular repair? J Trauma Acute Care Surg 2021; 90:384-387. [PMID: 33075025 DOI: 10.1097/ta.0000000000002995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The optimal management of minimal blunt thoracic aortic injuries (BTAIs) remains controversial, with experienced centers using therapy ranging from medical management (MM) to thoracic endovascular aortic repair (TEVAR). METHODS The Aortic Trauma Foundation registry was used to examine demographics, injury characteristics, management, and outcomes of patients with BTAI. RESULTS Two hundred ninety-six patients from 28 international centers were analyzed (mean age, 44.5 years [SD, 18 years]; 76% [225/296] male; mean Injury Severity Score, 34 [SD, 14]). Blunt thoracic aortic injury was classified as Grade I, 22.6% (67/296); Grade II, 17.6% (52/296); Grade III, 47.3% (140/296); and Grade IV, 12.5% (37/296). Overall aortic-related mortality (ARM) was 4.7% (14/296). Among all deaths, 33% (14/42) were ARM. Open repair was required for only 2%, with most undergoing TEVAR (58.4%) or MM (28.0%). Thoracic endovascular repair complications occurred in 3.4% (6/173), most commonly Type 1 endoleak (2.3%; 4/173). Among patients with minimal aortic injury (Grades I and II), 59.7% (71/119) received MM, while 40.3% (48/119) underwent TEVAR. Two patients initially managed with MM required subsequent TEVAR for injury progression during initial hospital stay. No significant difference in ARM between MM and TEVAR was noted for Grades I and II injuries. CONCLUSION A third of the trauma victims with BTAI succumb to ARM. Thoracic endovascular repair has replaced open repair but remains equivalent in outcomes to MM for minimal injuries. These data support MM of patients with minimal aortic injury. LEVEL OF EVIDENCE Therapeutic study, level IV.
Collapse
Affiliation(s)
- Joseph J DuBose
- From the R Adams Cowley Shock Trauma Center (J.J.D., J.M.), University of Maryland Medical System; Division of Vascular Surgery, University of Texas Health Sciences Center (K.C.-O., N.S.), Houston; Division of Vascular Surgery, University of Washington (B.S., E.Q.), Harborview; and Smidt Heart Institute (B.G., A.A.), Cedars-Sinai Medical Center, Los Angeles
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Halvachizadeh S, Mica L, Kalbas Y, Lipiski M, Canic M, Teuben M, Cesarovic N, Rancic Z, Cinelli P, Neuhaus V, Pape HC, Pfeifer R. Zone-dependent acute circulatory changes in abdominal organs and extremities after resuscitative balloon occlusion of the aorta (REBOA): an experimental model. Eur J Med Res 2021; 26:10. [PMID: 33478582 PMCID: PMC7818556 DOI: 10.1186/s40001-021-00485-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/11/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in severely injured patients with uncontrollable bleeding. However, zone-dependent effects of REBOA are rarely described. We compared the short-term zone- and organ-specific microcirculatory changes in abdominal organs and the extremity during occlusion of the aorta in a standardized porcine model. Methods Male pigs were placed under general anesthesia, for median laparotomy to expose intra-abdominal organs. REBOA placement occurred in Zone 1 (from origin left subclavian artery to celiac trunk), Zone 2 (between the coeliac trunk and most caudal renal artery) and Zone 3 (distal most caudal renal artery to aortic bifurcation). Local microcirculation of the intra-abdominal organs were measured at the stomach, colon, small intestine, liver, and kidneys. Furthermore, the right medial vastus muscle was included for assessment. Microcirculation was measured using oxygen-to-see device (arbitrary units, A.U). Invasive blood pressure measurements were recorded in the carotid and femoral artery (ipsilateral). Ischemia/Reperfusion (I/R)-time was 10 min with complete occlusion. Results At baseline, microcirculation of intra-abdominal organs differed significantly (p < 0.001), the highest flow was in the kidneys (208.3 ± 32.9 A.U), followed by the colon (205.7 ± 36.2 A.U.). At occlusion in Zone 1, all truncal organs showed significant decreases (p < 0.001) in microcirculation, by 75% at the colon, and 44% at the stomach. Flow-rate changes at the extremities were non-significant (n.s). During occlusion in Zone 2, a significant decrease (p < 0.001) in microcirculation was observed at the colon (− 78%), small intestine (− 53%) and kidney (− 65%). The microcirculatory changes at the extremity were n.s. During occlusion in Zone 3, truncal and extremity microcirculatory changes were n.s. Conclusion All abdominal organs showed significant changes in microcirculation during REBOA. The intra-abdominal organs react differently to the same occlusion, whereas local microcirculation in extremities appeared to be unaffected by short-time REBOA, regardless of the zone of occlusion.
Collapse
Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Ladislav Mica
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Miriam Lipiski
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marko Canic
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nikola Cesarovic
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zoran Rancic
- Department of Vascular Surgery, University Hospital Zürich, Raemistrasse 100, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Valentin Neuhaus
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Hans- Christoph Pape
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
33
|
Bae M, Jeon CH, Kwon H, Kim JH, Choi SU, Song S. Evaluation of Zone 2 Thoracic Endovascular Aortic Repair Performed with and without Prophylactic Embolization of the Left Subclavian Artery in Patients with Traumatic Aortic Injury. Korean J Radiol 2021; 22:577-583. [PMID: 33543841 PMCID: PMC8005354 DOI: 10.3348/kjr.2020.0989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report the authors' experience in performing thoracic endovascular aortic repair (TEVAR) for zone 2 lesions after traumatic aortic injury (TAI). MATERIALS AND METHODS This retrospective review included 10 patients who underwent zone 2 TEVAR after identification of aortic isthmus injury by CT angiography (CTA) upon arrival at the emergency room of a regional trauma center from 2016 to 2019. Patients were classified into two groups: those who underwent left subclavian artery (LSA) embolization concurrently with the main TEVAR procedure, and those in whom LSA embolization was not performed during the main procedure, but was planned as a bailout treatment if type II endoleak was noted on follow-up CTA images. Pre-procedural and procedure-related factors and post-procedure prognosis were compared between the groups. RESULTS There were no differences in pre-procedural factors, occurrence of endoleaks, and post-procedure prognosis (including mortality) between patients in the two groups. The duration of the procedure was shorter in the non-LSA embolization group (61 minutes vs. 27 minutes, p = 0.012). During follow-up, type II endoleak did not occur in either group. CONCLUSION Delaying preventative LSA embolization until stabilization of the patient would be desirable when performing zone 2 TEVAR for TAI, in the absence of endoleak on the completion aortography image taken after complete deployment of the stent graft.
Collapse
Affiliation(s)
- Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Chang Ho Jeon
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Radiology, Pusan National University Hospital, Busan, Korea.
| | - Hoon Kwon
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Radiology, Pusan National University Hospital, Busan, Korea
| | - Jin Hyeok Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seon Uoo Choi
- Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| |
Collapse
|
34
|
Zambetti BR, Huang DD, Lewis RH, Fischer PE, Croce MA, Magnotti LJ. Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury. J Am Coll Surg 2020; 232:416-422. [PMID: 33348014 DOI: 10.1016/j.jamcollsurg.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.
Collapse
Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Dih-Dih Huang
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Richard H Lewis
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Peter E Fischer
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN.
| |
Collapse
|
35
|
Wang SK, Severance S, Troja W, Drucker NA, Gray BW, Rouse TM, Dalsing MC, Maijub JG. Operative Traumatic Aortic Injuries at an Urban Pediatric Hospital. Am Surg 2020; 87:965-970. [PMID: 33291946 DOI: 10.1177/0003134820966272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Limited data are available describing the long-term results of pediatric patients undergoing aortic repair secondary to trauma. Therefore, this descriptive investigation was completed to abrogate this deficit. METHODS A retrospective review of an urban level 1 pediatric trauma database maintained at a high-volume dedicated children's hospital between 2008-2018 was completed to capture all cases of severe traumatic aortic injury and associated demographics, mechanisms, injury severity, treatment, and clinical outcomes. RESULTS In the prespecified interval, 2189 children (age <18 years) presented to our facility as a level 1 trauma activation. Of these cases, a total of 10 patients (.5%) had a demonstrable thoracic or abdominal aortic injury. The mean age of our study cohort was 10.4 ± 5.7 years. The mechanism of injury consisted of 8 participants involved in motor vehicle accidents, 1 pedestrian struck by a vehicle, and 1 struck by a falling boulder. Injuries were identified via CT angiogram (n = 9) or autopsy (n = 1) and consisted of 6 thoracic aortas and 4 abdominal aortas. The mean trauma injury severity score was 37.6 ± 19.9. Seven of the patients underwent open surgical intervention, 1 underwent endovascular intervention, 1 was treated with medical management, and 1 patient expired in the trauma bay before surgery could be performed. Aortic pathologies observed were 6 transections, 2 dissections, and 2 occlusions. Five of the ten patients underwent nonaortic surgical procedures. To determine operative outcomes, we excluded the 2 patients who did not receive aortic intervention. In the 8 remaining patients, the mean hospital length of stay was 12.8 ± 4.8 days with 6.8 ± 4.1 days in the intensive care unit. All 9 participants who survived the initial trauma evaluation were discharged from the hospital. Mean follow-up was 38.3 ± 43.0 months; during which, we observed no additional aortic-related morbidity, mortality, and reinterventions. The only stent-graft deployed remained in stable position without evidence of endoleak or migration by duplex. CONCLUSION Traumatic aortic injury is exceedingly rare in children and primarily of blunt etiology. Of the patients who survive the scene, operative repair seems to be associated with excellent perioperative and long-term survival.
Collapse
Affiliation(s)
- Shihuan K Wang
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Sarah Severance
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Weston Troja
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Natalie A Drucker
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Brian W Gray
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Thomas M Rouse
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Michael C Dalsing
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - John G Maijub
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| |
Collapse
|
36
|
Sarquis LM, Michaelis W, Santos AL, Pinto CS, Yokoyama RA, Seguro EF, Martins ALDC, do Vale VB. Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases. J Vasc Bras 2020; 19:e20200074. [PMID: 34211523 PMCID: PMC8218017 DOI: 10.1590/1677-5449.200074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown. Objectives The aim of this study is to describe a specialist trauma center’s experience with endovascular treatment of cases like these. Methods This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil). Results Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection). Conclusions The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.
Collapse
Affiliation(s)
| | - Wilson Michaelis
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | - Antonio Lacerda Santos
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | | | - Rogerio Akira Yokoyama
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | | | | | | |
Collapse
|
37
|
Kapoor H, Lee JT, Orr NT, Nisiewicz MJ, Pawley BK, Zagurovskaya M. Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management. Radiographics 2020; 40:1834-1847. [PMID: 33006921 DOI: 10.1148/rg.2020200066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.
Collapse
Affiliation(s)
- Harit Kapoor
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - James T Lee
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Nathan T Orr
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Michael J Nisiewicz
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Barbara K Pawley
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Marianna Zagurovskaya
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| |
Collapse
|
38
|
Patel HJ, Azizzadeh A, Matsumoto AH, Velazquez OC, Rovin JD, Lombardi JV, Khoynezhad A, Dai Y, White RA. Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury. Ann Thorac Surg 2020; 110:815-820. [DOI: 10.1016/j.athoracsur.2019.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/24/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022]
|
39
|
Alarhayem AQ, Rasmussen TE, Farivar B, Lim S, Braverman M, Hardy D, Jenkins DJ, Eastridge BJ, Cestero RF. Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era. J Vasc Surg 2020; 73:896-902. [PMID: 32682070 DOI: 10.1016/j.jvs.2020.05.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.
Collapse
Affiliation(s)
| | - Todd E Rasmussen
- Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Md.
| | - Behzad Farivar
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sungho Lim
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Max Braverman
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - David Hardy
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Donald J Jenkins
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Brian J Eastridge
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Ramon F Cestero
- University of Texas Health Science Center at San Antonio, San Antonio, Tex
| |
Collapse
|
40
|
Kim M, Moore JE. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:61-68. [PMID: 32435162 PMCID: PMC7223697 DOI: 10.1007/s40140-020-00374-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose of Review This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury. Recent Findings Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described. Summary Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.
Collapse
Affiliation(s)
- Michelle Kim
- 1University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, MD USA
| | - James E Moore
- 2Consultant Anaesthetist, Intensive Care Physician & Director of Trauma Services, Wellington Hospital, Wellington, New Zealand
| |
Collapse
|
41
|
Romagnoli AN, Dubose JJ. Unmet needs in the management of traumatic aortic injury. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01429-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
42
|
Long D, Hessel M. A Case of Traumatic Aortic Transection Presenting With Hemorrhagic Shock. J Emerg Med 2020; 58:e201-e205. [PMID: 32229138 DOI: 10.1016/j.jemermed.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/28/2020] [Accepted: 02/16/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aortic transection, or aortic rupture, is a rare diagnosis in trauma patients and carries a high mortality. CASE REPORT We present the case of a 61-year-old man presenting to a Level I trauma center after being struck by a motor vehicle, found to have an aortic transection. He was initially hypotensive and resuscitated with blood products due to concern for hemorrhagic shock. Aortic injury was suspected after chest x-ray study demonstrated a widened mediastinum. Traumatic thoracic aortic transection with pseudoaneurysm was diagnosed on computed tomography of the aorta, and the patient was taken to the operating room for thoracic endovascular repair of the aorta. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diagnosis of aortic injury can be challenging, especially in trauma patients presenting with hypotension. Aortic injury must be suspected in patients presenting after a high-velocity mechanism injury. It is an uncommon cause of hemorrhagic shock in trauma patients and must be considered even if other traumatic injuries are identified, as it commonly occurs with other significant injuries. Although chest x-ray study can be useful, a negative chest x-ray study does not rule out aortic injury. Aortic injury is a time-sensitive diagnosis, and early identification is key to these patients surviving to receive definitive management in the operating room.
Collapse
Affiliation(s)
- Drew Long
- Department of Emergency Medicine, Brooke Army Military Medical Center, Fort Sam Houston, Texas
| | - Matthew Hessel
- Department of Emergency Medicine, Brooke Army Military Medical Center, Fort Sam Houston, Texas
| |
Collapse
|
43
|
A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis. Ann Surg 2019; 270:612-619. [DOI: 10.1097/sla.0000000000003486] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
44
|
|