Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

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

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.

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

Blunt thoracic aortic injury diagnosis and management: two decades of innovation from Memphis

In recognition of Dr Timothy Fabian's sentinel contributions to the field of trauma surgery, this review highlights his contributions to the diagnosis and management of blunt thoracic aortic injury and places his contributions into context relative to current practice.

Minimal Aortic Injury Detected on Computed Tomography Angiography during Initial Trauma Imaging: Single Academic Level 1 Trauma Center Experience

BACKGROUND

 Minimal aortic injury (MAI), a subtype of acute traumatic aortic injury, is being increasingly recognized with better imaging techniques. Given conservative management, the role of follow-up imaging albeit important yet has to be defined.

METHODS

 All trauma chest computed tomography angiographies (CTAs) at our center between January 2012 and January 2019 were retrospectively reviewed for presence of MAI. MAIs were generally reimaged at 24 to 72 hours and then at a 7- and 30-day interval. Follow-up CTAs were reviewed for stability, progression, or resolution of MAI, along with assessment of injury severity scores (ISS) and concomitant injuries, respectively.

RESULTS

 A total of 17,569 chest CTAs were performed over this period. Incidence of MAI on the initial chest CTA was 113 (0.65%), with 105 patients receiving follow-up CTAs. The first, second, third, and fourth follow-up CTAs were performed at a median of 2, 10, 28, and 261 days, respectively. Forty five (42.9%), 22 (21%), 5 (4.8%), and 1 (1%) of the MAIs were resolved by first, second, third, and fourth follow-up CTAs. Altogether, 21 patients showed stability (mean ISS of 16.6), and 11 demonstrated improvement (mean ISS 25.8) of MAIs. Eight patients had no follow-up CTA (mean ISS 21). No progression to higher-grade injury was observed. Advancing age decreased the odds of MAI resolution on follow-up. A possible trend (p-value 0.22) between increasing ISS and time to resolution of MAIs was noted.

CONCLUSION

 In our series of acute traumatic MAIs diagnosed on CTA imaging, there was no progression of injuries with conservative management, questioning the necessity of sequential follow-up imaging.

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

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.

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

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.

Outcomes of Operative and Non-Operative Management in Blunt Thoracic Aortic Injury

OBJECTIVES

Although current guidelines for management of blunt traumatic aortic injury (BTAI) recommend intervention for grade 2 injury or higher, there is a national trend of aggressive endovascular treatment of low-grade BTAI. Little is known about the natural history of grade 1-2 injuries treated non-operatively. We hypothesized that most of these low-grade injuries remain stable with non-operative management.

METHODS

A review of blunt thoracic aortic injuries (BTAI) at a large referral Level 1 trauma center from 2004-2020 was performed. Injuries were graded on a standard 1-4 scale. Outcomes of both non-operative and TEVAR management strategies were compared, including post-trauma morbidity, mortality, re-intervention, and lesion stability.

RESULTS

176 patients with BTAI, sufficient imaging, and follow-up were identified during the time period. 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with grade 4 injury. Of those 176 patients, 112 underwent thoracic endovascular aortic repair (TEVAR) and 64 were managed non-operatively. Most (90.2%) undergoing TEVAR had grade 3 injuries. Non-operative management was performed for 97.2% of grade 1 injuries and 62.5% of grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). Post-trauma morbidity within 30 days (stroke [3.6 vs. 3.1%], MI/arrhythmia [8.9 vs. 1.6%], respiratory failure [31.2 vs. 28.1%], acute kidney injury [9.8 vs. 12.5%], UTI [2.7 vs. 4.8%], GI bleeding [3.6 vs. 0.0%], PE [10.9 vs. 4.5%]) and 1-year mortality after discharge [1.8 vs. 3.1%] were comparable between operative and non-operative groups. Median [IQR] follow up was 1501 [475.6, 2804] days in the TEVAR group and 1170.5 [317, 2173] days in the non-operative group. There was no progression of lesions in patients with low-grade (1-2) injuries managed non-operatively. Resolution of grade 1-2 injury was seen in 20% of patients at 30 days, improving to 44% during long-term follow up. Fourteen patients with grade 3 injuries (12.2% of grade 3 injuries in this series) were also observed and did not require future intervention. These patients generally had smaller pseudoaneurysms with minimal periaortic hematoma. None progressed or resulted in rupture on follow-up (454.5 [81, 1199] days CT scan follow up).

CONCLUSIONS

Non-operative management of low-grade BTAI does not result in long-term aortic complications or need for reintervention. Those grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma may be safely observed if they can be appropriately followed, and that indications for treatment of select grade 3 injuries merits further consideration.

Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury

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.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Traumatic Aortic Injury: Sailing Close to the Wind

Blunt aortic injuries are lethal and only a few patients survive. Most of the patients die at the site of accidents and only a few reach the hospital. Those who reach hospitals usually have small tears or pseudo-aneurysm of the aorta. Immediate imaging and intervention play a major role in the survival of these patients. We report this case as only a few patients report to the hospital with aortic injury and our patient was taken up for surgery immediately and a life-saving procedure was done.

Torso vascular trauma

Vascular injury within the chest or abdomen represents a unique challenge to the pediatric general surgeon, as these life- or limb-threatening injuries are rare and may require emergent treatment. Vascular injury may present as life-threatening hemorrhage, or with critical ischemia from intimal injury, dissection, or thrombosis. Maintaining the skillset and requisite knowledge to address these injuries is of utmost importance for pediatric surgeons that care for injured children, particularly for surgeons practicing in freestanding children's hospitals that frequently do not have adult vascular surgery coverage. The purpose of this review is to provide an overview of torso vascular trauma, with a specific emphasis in rapid recognition of torso vascular injury as well as both open and endovascular management options. Specific injuries addressed include blunt and penetrating mediastinal vascular injury, subclavian injury, abdominal aortic and visceral segment injury, inferior vena cava injury, and pelvic vascular injury. Operative exposure, vascular repair techniques, and damage control options including preperitoneal packing for pelvic hemorrhage are discussed. The role and limitations of endovascular treatment of each of these injuries is discussed, including endovascular stent graft placement, angioembolization for pelvic hemorrhage, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in children.

Acute traumatic injury of the aorta: presentation, diagnosis, and treatment

Despite advances in detection and treatment, acute traumatic aortic injury (ATAI) is associated with high rates of morbidity and mortality. Both physical and hemodynamic forces have been postulated as mechanisms of aortic injury during a traumatic event. For patients who survive the initial injury, rapid detection is critical for diagnosis and procedural planning, which requires a thorough knowledge of both its clinical presentation and the available diagnostic imaging modalities. Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) can each have a role in the diagnosis of ATAI. After stabilization of the patient, the management of ATAI is guided by the severity of injury. Appropriately selected patients with low grade injuries may be managed non-operatively. When treatment is required, there are both open surgical and endovascular options. In current practice, endovascular approaches with stent-graft placement are preferred due to their high clinical success and low rates of complications. Complications from endograft placement can include: endoleak, endograft collapse, infection, endograft failure, and endograft migration. Open surgical repair is now reserved for patients with unfavorable anatomy for endovascular therapies. This review provides a comprehensive overview of ATAI including its epidemiology and demographics, mechanisms of injury, clinical and radiographic diagnosis, treatment options, and post-therapeutic follow-up.

Thoracic Trauma: Aortic Injuries

Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.

A Rapid Diagnosis and Treatment of a Traumatic Aortic Transection: A Case of Survival to the ICU

We present the case of a young man with traumatic aortic dissection secondary to a motor vehicle collision. While the differential diagnosis for traumatic injury after a motor vehicle collision can include commonly studied and trained for cases, such as pneumo/hemothorax, pulmonary contusion, splenic laceration, and pelvic fractures, for example, one of the more deadly and hence rare presentations of motor vehicle trauma is aortic transection. The fact that the diagnostic studies included as part of the initial Advanced Trauma Life Support^® (ATLS^®) trauma survey are not well equipped to diagnose such an injury is also a deadly factor. In this case review, we explore factors affecting the timely diagnosis, management, and outcomes of traumatic aortic injury. Prompt diagnosis is imperative in order to save a patient's life.

Management of Moderate Blunt Thoracic Aortic Injuries in Patients with Intracranial Hemorrhage

BACKGROUND

Blunt thoracic aortic injuries (BTAIs) are the second most common cause of death due to blunt-force trauma in the United States. Patients with minimal injuries do not typically require surgical repair, whereas patients with severe injuries are treated emergently. Moderate aortic injuries are repaired in a semielective fashion, but the optimal management of patients with moderate BTAI with associated intracranial hemorrhage (ICH) is unknown. We sought to analyze the management and outcomes of patients presenting with concomitant moderate BTAI and ICH.

METHODS

Consecutive patients who received a thoracic endovascular aortic repair (TEVAR) at our institution for treatment of moderate BTAI between January 2014 and December 2017 were retrospectively reviewed as part of an institutional review board-approved protocol. Patients were classified by our BTAI classification into "minimal", "moderate", or "severe". ICH was identified on computed tomography scan and its severity determined by the neurosurgical team. Outcome measures included surgical timing and surgical outcomes.

RESULTS

Fifty-two patients had a moderate BTAI and underwent TEVAR, 20 (38 %) of whom presented with ICH. Median time from admission to surgery was 58.5 hr for patients with ICH and 26.5 hr for non-ICH patients. Intraoperative heparin was administered in all patients without ICH and in 19 of 20 (95%) patients with ICH after the ICH met criteria for stability. Protamine reversal was utilized in 80% of patients with ICH and 75% of non-ICH patients. No patient developed ischemic stroke or spinal cord ischemia. Worsening ICH was seen in only one patient, who also received heparin infusion for pulmonary embolus 24 hr before TEVAR. There were no aortic-related mortalities in either group. Thirty-day all-cause mortality was 5% for patients with ICH and 3% for non-ICH patients.

CONCLUSIONS

Patients with moderate BTAI and stable ICH are not at increased risk of TEVAR-related complications. Administration of intraoperative heparin during TEVAR appears to be safe and does not worsen ICH.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury

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.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management

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.

Minor aortic injury may be at risk of progression from uncontrolled shear stress: An in-vitro model demonstrates aortic lesion expansion

Background

Non-operative management is considered appropriate treatment for minor aortic injury, while blood pressure and anti-impulse therapy are routinely utilized to prevent higher grade aortic injury progression. However, a universal medical regimen for low grade intimal injuries has not been adopted and risks of low-grade injury progression not well described. The purpose of this study is to determine the fracture response of minimally damaged aortic tissue to the various applied forces. Our hypothesis is that internal circumferential shear within the aortic wall is a primary fracture mode. This knowledge may help guide clinical management to minimize risk of injury progression, including instituting standard medical regimens with anti-impulse therapy and β-blockade for such minor injuries.

Methods

Human ascending aortic tissue was obtained after aneurysm repair or heart transplant, stored at 4°C and tested within 48 hours. Minor injury was modeled with a small radial notch on the luminal aspect of aortic rings, circumferentially expanded under video acquisition and analyzed to determine lesion propagation.

Results

15 rings were obtained from 8 aneurysmal and 4 healthy aortas. All specimens demonstrated circumferential crack propagation. Propagation was longer (8.02 ± 5.92 mm vs 2.70 ± 1.23 mm) and initiation of crack propagation earlier in aneurysmal tissue (1.54 ± 0.17 versus 1.90 ± 0.17 times initial diameter).

Conclusions

Dilation of minimally injured aortic rings is associated with lesion expansion and injury progression in all specimens including healthy and aneurysmal tissue. This propagation illustrates the mechanical response to increased levels of internal shear, compromising structural integrity and increasing risk of aortic rupture in all injured aortas. Shear forces are routinely generated through normal circumferential aortic expansion with each pulsation, the magnitude of these forces determined by pulse and blood pressure. This suggests minor aortic injuries are not trivial and strategies to reduce shear stress be implemented in all such patients without contraindications to β- blockers.

Finite Element Analysis of the Mechanism of Traumatic Aortic Rupture (TAR)

As many as 80% of patients with TAR die on the spot while out of those reaching a hospital, 30% would die within 24 hours. Thus, it is essential to better understand and prevent this injury. The exact mechanics of TAR are unknown. Although most researchers approve it as a common-sense deceleration injury, the exact detailed mechanism of TRA still remains unidentified. In this work, a deceleration mechanism of TAR was carried out using finite element analysis (FEA). The FE analysis aimed to predict internal kinematics of the aorta and assist to comprehend the mechanism of aorta injury. The model contains the heart, lungs, thoracic aorta vessel, and rib cage. High-resolution computerized tomography (HR CT scan) was used to provide pictures that were reconstructed by MIMICS software. ANSYS FE simulation was carried out to investigate the behavior of the aorta in the thoracic interior after deceleration occurred during a car crash. The finite element analysis indicated that maximum stress and strain applied to the aorta were from 5.4819e5 to 2.614e6 Pa and 0.21048 to 0.62676, respectively, in the Y-direction when the initial velocity increased from 10 to 25 m/s. Furthermore, in the X-direction when the velocity changed from 15 to 25 m/s, the stress and strain values increased from 5.17771e5 to 2.3128e6 and from 0.22445 to 0.618, respectively.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

Purpose

Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).

Methods

Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.

Results

Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).

Conclusion

This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01432-y) contains supplementary material, which is available to authorized users.

Blunt thoracic aortic injury - concepts and management

BACKGROUND

Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important.

MAIN BODY

Blunt thoracic aortic injury may be fatal if not diagnosed and treated expeditiously. Endovascular options allow safe and effective management of these dangerous injuries. This paper describes the overview of blunt thoracic aortic trauma, the epidemiology, presentation, diagnosis, and treatment options with a focus on endovascular management.

CONCLUSION

Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.

A Case of Traumatic Aortic Transection Presenting With Hemorrhagic Shock

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.

Hemothorax resulting from an initially masked aortic perforation caused by penetration of the sharp edge of a fractured rib: A case report

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Rare aortic injury from a rib fracture, which is not found in primary evaluation.

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Hemothorax with great vessel injury can be fatal and should be detected using computed tomography.

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Some great vessel injuries cannot be detected through contrast-enhanced chest computed tomography.

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Great vessel injury should be considered in hemothorax with multiple rib fractures.

Introduction

There are multiple causes of hemothorax in blunt chest trauma. However, a traumatic hemothorax with an uncertain cause is potentially life-threatening without treatment, because an undetected and hidden great vessel injury can remain unknown. Delayed diagnosis can lead to death.

Presentation of case

A 77-year-old man was transferred to a local hospital, after experiencing a 3-m fall. Contrast CT of the chest revealed a left clavicle fracture, multiple left rib fractures and hemopneumothorax, but no obvious signs of great vessel injury, such as aortic injury. His condition was stable, owing to the chest tube thoracostomy with 800 ml blood output and intravenous fluid. The patient was then transferred to our hospital for further treatment. However, his condition rapidly deteriorated in the ambulance on the way to our hospital, and he needed a blood transfusion. On arrival, he was in shock, with his vital signs compromised due to blood loss. Emergency open thoracotomy was performed to explore the bleeding point and stop hemorrhaging. Intraoperative findings revealed sharp edges of the fractured fourth and fifth left ribs to be protruding into the chest cavity toward the descending aorta and causing an aortic pinhole injury. Ruptured aorta was repaired with a pledget-armed sutures and the sharp fractured ribs were resected. The patient was discharged, uneventfully, 35 days after the operation.

Conclusion

This case suggests that even if great vessel injury is not detected on contrast CT at admission, it should always be considered especially in a hemothorax case with multiple rib fractures.

A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients

BACKGROUND

Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications.

METHODS

We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender.

RESULTS

We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I² = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I² = 52%; P = .03), 0% (95% CI, 0%-2.0%; I² = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I² = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I² = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I² = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I² = 65%; P < .01), 0% (95% CI, 0%-1.8%; I² = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I² = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I² = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (β = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (β = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (β = .54; 95% CI, 0.3-0.90).

CONCLUSIONS

This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

Die traumatische Aortenruptur

Verkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.

Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.

Blunt traumatic scapular fractures are associated with great vessel injuries in children

BACKGROUND

Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients.

METHODS

Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC).

RESULTS

We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck).

CONCLUSIONS

Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients.

LEVEL OF EVIDENCE

Epidemiologic and prognostic study, level III; Therapeutic, level IV.

A case of traumatic thoracic aorta rupture - A life threatening emergency

Traumatic aortic transection is a life threatening emergency where there is a near-complete tear through all the layers of the aorta due to trauma. This condition is most often lethal and requires immediate medical attention. Symptoms of an aortic rupture may include severe chest pain, back pain, abdominal pain and signs of external chest injury. Treatment should be prompt in hemodynamically unstable patient in the form of endovascular or open surgical technique. We present a twenty nine year old male with aortic transection following motor vehicle accident where an interposition tube graft was placed after trimming the lacerated segments of the aorta under cardiopulmonary bypass. The patient is doing well with two years of follow up at our institution.

A systematic review of nonoperative management in blunt thoracic aortic injury

OBJECTIVE

The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI).

METHODS

A systematic search of MedLine, Embase, and Cochrane Central was completed to identify original articles reporting injury characteristics and outcomes in patients with BTAI managed nonoperatively during their index hospitalization. Article title and abstract screening, full-text review, and data abstraction were performed in duplicate, with discrepancies resolved by a third reviewer. The quality of each study was evaluated using the Oxford Centre for Evidence-Based Levels of Evidence.

RESULTS

Of 2162 identified studies, 74 were included and reported on 8606 patients with BTAI who were managed nonoperatively between 1970 and 2016. Only one study was prospective. The median nonoperative sample size per study was 11 patients. The characterization of aortic injury grade differed across studies. Follow-up varied widely from 1 day to 118 months. Injury healing or improvement on follow-up imaging occurred in 34% (226 of 673 patients; reported in 37 studies), most often in the context of grade I intimal injury. Injury progression or requirement for a thoracic endovascular aneurysm repair for injury progression was 7.6% (66 of 873 patients; reported in 46 studies). A total of 37 studies reported aortic-related death, with an overall rate of 4.5% (37 of 827 patients) and a rate of 1% in grade I and II injuries (1 of 153 patients) and 18% in grade III and IV (9 of 50 patients).

CONCLUSIONS

An increasing number of reports support nonoperative management of grade I intimal injury, consistent with Society for Vascular Surgery guidelines. However, a retrospective interpretation of the determinants of management, heterogeneous injury characterization, and variable follow-up remain major limitations to the informed use of nonoperative management across all BTAI grades.

Implementation and results of a practical grading system for blunt thoracic aortic injury

OBJECTIVE

We previously proposed a grading system for blunt thoracic aortic injury (BTAI) designed to guide therapy. This study analyzed our outcomes since implementing this system.

METHODS

A single-center, retrospective study was conducted of consecutive patients presenting with BTAI between January 2014 and December 2017. This grading system classified injuries into minimal, moderate, or severe on the basis of computed tomography imaging. Primary end points included timing of operation and mortality. Secondary end points included associated injuries, aortic anatomy, and operative details as well as 30-day follow-up.

RESULTS

During the study period, 87 patients with BTAI were identified. The majority of patients had a moderate injury occurring just distal to the left subclavian artery (LSA); 59 patients underwent thoracic endovascular aortic repair (TEVAR), whereas none of the patients with minimal injury (n = 24) required surgical treatment. The mean time to repair was 53 hours (1-191 hours) for moderate injury and 3.6 hours (0-7 hours) for severe injury. The average diameter and length of the endograft was 26 mm and 112 cm, respectively, and the LSA was covered in 42% of patients. Intravascular ultrasound to confirm sizing was used in 83% of cases. Most patients (92%) received intravenous heparin during TEVAR; the remainder received only heparin sheath flush because of concern for intracranial hemorrhage. None of the patients underwent LSA revascularization or developed stroke or spinal cord ischemia as a result of the procedure. Operative complications were seen in 6% of patients and included 1 femoral pseudoaneurysm, 1 lower extremity compartment syndrome, 1 type II endoleak requiring LSA embolization, and 1 intracranial bleed. The 30-day mortality was 7% (one aorta-related death). On 30-day postoperative follow-up, computed tomography imaging uniformly revealed positive aortic remodeling, and no secondary aortic intervention was required.

CONCLUSIONS

Institutional implementation of our grading system has streamlined treatment of BTAI, and our results confirm the following: patients with minimal injury do not require surgical treatment; patients with moderate injury can safely undergo TEVAR in a semielective manner once they are stable from other injuries; and patients with severe injury require emergent repair. These procedures are expeditious and can be successfully performed percutaneously with a single endograft. Complications are rare, and follow-up reveals excellent remodeling of the aorta, likely resulting in lengthened interval surveillance requirements for these patients.

Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges

Blunt thoracic aortic injuries are rare occurrences but carry an increased risk of mortality. Over the last two decades, however, major advances in diagnostic imaging, staging, and treatment have significantly improved outcomes. Modern imaging paved the way for a new staging system based on the anatomical layers of the aortic wall. This staging system, in turn, allowed for refinement of treatment, which now includes nonoperative management with anti-impulse therapy, endovascular intervention, and, if needed, open surgical repair. As is the case with any other rapidly evolving therapy, however, new challenges and controversies arise. The resolution of these challenges will rely on a broad, international, and multidisciplinary effort. (This is a review article based on the invited lecture of the 46th Annual Meeting of Japanese Society for Vascular Surgery.)

Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment

Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.

History and significance of the trauma resuscitation flow sheet

There is little to no written information in the literature regarding the origin of the trauma flow sheet. This vital document allows programs to evaluate initial processes of trauma care. This information populates the trauma registry and is reviewed in nearly every Trauma Process Improvement and Patient Safety conference when discerning the course of patient care. It is so vital, a scribe is assigned to complete this documentation task for all trauma resuscitations, and there are continual process improvement efforts in trauma centers across the nation to ensure complete and accurate data collection. Indeed, it is the single most important document reviewed by the verification committee when evaluating processes of care at site visits. Trauma surgeons often overlook its importance during resuscitation, as recording remains the domain of the trauma scribe. Yet it is the first document scrutinized when the outcome is less than what is expected. The development of the flow sheet is not a result of any consensus statement, expert work group, or mandate, but a result of organic evolution due to the need for relevant and better data. The purpose of this review is to outline the origin, importance, and critical utility of the trauma flow sheet.

Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows

OBJECTIVES

The objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy.

METHODS

From January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores.

RESULTS

All but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, P = 0.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1 year, 68.2%, 80.8% and 79.4% at 5 years and 63.9%, 72.7% and 79.4% at 10 years, respectively (log-rank = 0.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; P = 0.021], Trauma Injury Severity Score >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011).

CONCLUSIONS

Minimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage.

Delay of computed tomography is associated with poor outcome in patients with blunt traumatic aortic injury: A nationwide observational study in Japan

According to guidelines from the Eastern Association for the Surgery of Trauma, computed tomography (CT) with intravenous contrast is strongly recommended to diagnose clinically significant blunt traumatic aortic injury (BTAI). However, it remains unclear whether the timing of CT scanning is associated with the prognosis of BTAI patients.We extracted data on emergency patients who suffered a BTAI in the chest and/or the abdomen from 2004 to 2015 from the Japanese Trauma Data Bank, a nationwide trauma registry. The primary outcome was death in the emergency department (ED) and secondary outcome was discharge to death. In addition, we assessed the relationship between death in the ED and the timing of CT scanning by shock status in subgroup analysis. We divided these patients into the tertile groups of early (≤26 minutes), middle (27-40 minutes), and late (≥41 minutes) phases based on the time interval from hospital arrival to start of first CT scanning, and assessed death of BTAI patients in the ED by CT scanning time with the use of a multivariable logistic regression model.In total, 421 patients who suffered BTAI in the chest and/or the abdomen were eligible for our analysis. The proportion of patients dying at hospital admission was 7.7% (11/142) in the early group, 11.1% (15/135) in the middle group, and 17.6% (25/144) in the late group. In a multivariable logistic regression adjusted for confounding factors, the adjusted odds ratio (AOR) of death in the ED was 1.833 (95% confidence interval [CI]: 0.601-5.590, P = .287) in the middle group and 2.832 (95% CI: 1.007-7.960, P = .048) in the late group compared with the early group. Compared with the early group, the late group tended to have a higher rate of discharge to death (AOR: 1.438, 95% CI: 0.735-2.813). In the patients with shock, the AOR was 3.292 (95% CI: 0.495-21.902) in the middle group and 6.039 (95% CI: 0.990-36.837) in the late group compared with the early group.This study revealed that a longer time interval from hospital arrival to CT scanning was associated with higher mortality in the ED in patients with BTAI.

Traumatic abdominal aortic injury: clinical considerations for the diagnostic radiologist

Traumatic abdominal aortic injury (TAAI) is a severe complication of penetrating and blunt trauma with significant morbidity and mortality, particularly if diagnosis is delayed. In patients with life-threatening injuries, accurate and prompt diagnosis of TAAI can be made with computed tomography (CT). Once the diagnosis of TAAI is made, the radiologist should provide an accurate description of the aortic lesion and the extent of injury in order to guide management whether it be non-operative, open aortic repair, or endoluminal stent repair. The purpose of this article is to review the key imaging aspects of TAAI and to discuss how the key CT imaging findings affect clinical management.

Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury

OBJECTIVE

The traditional approach to stable blunt thoracic aortic injury (BTAI) endorsed by the Society for Vascular Surgery is early (<24 hours) thoracic endovascular aortic repair (TEVAR). Recently, some studies have shown improved mortality in stable BTAI patients repaired in a delayed manner (≥24 hours). However, the indications for use of delayed TEVAR for BTAI are not well characterized, and its overall impact on the patient's survival remains poorly understood. We sought to determine whether delayed TEVAR is associated with a decrease in mortality compared with early TEVAR in this population.

METHODS

We conducted a retrospective cohort study of adult patients with BTAI (International Classification of Diseases, Ninth Revision diagnosis code 901.0) who underwent TEVAR (International Classification of Diseases, Ninth Revision procedure code 39.73) from 2009 to 2013 using the National Sample Program data set. Missing physiologic data were imputed using chained multiple imputation. Patients were parsed into groups based on the timing of TEVAR (early, <24 hours, vs delayed, ≥24 hours). The χ², Mann-Whitney, and Fisher exact tests were used to compare baseline characteristics and outcomes of interest between groups. Multivariable logistic regression for mortality was performed that included all variables significant at P ≤ .2 in univariate analyses.

RESULTS

A total of 2045 adult patients with BTAI were identified, of whom 534 (26%) underwent TEVAR. Patients with missing data on TEVAR timing were excluded (n = 27), leaving a total of 507 patients for analysis (75% male; 69% white; median age, 40 years [interquartile range, 27-56 years]; median Injury Severity Score [ISS], 34 [interquartile range, 26-41]). Of these, 378 patients underwent early TEVAR and 129 underwent delayed TEVAR. The two groups were similar with regard to age, sex, race, ISS, and presenting physiology. Mortality was 11.9% in the early TEVAR group vs 5.4% in the delayed group, with the early group displaying a higher odds of death (odds ratio, 2.36; 95% confidence interval, 1.03-5.36; P = .042). After adjustment for age, ISS, and admission physiology, the association between early TEVAR and mortality was preserved (adjusted odds ratio, 2.39; 95% confidence interval, 1.01-5.67; P = .047).

CONCLUSIONS

Consistent with current Society for Vascular Surgery recommendations, more BTAI patients underwent early TEVAR than delayed TEVAR during the study period. However, delayed TEVAR was associated with significantly reduced mortality in this population. Together, these findings support a need for critical appraisal and clarification of existing practice guidelines in management of BTAI. Future studies should seek to understand this survival disparity and to determine optimal selection of patients for early vs delayed TEVAR.

Limited influence of blunt aortic injuries on the outcome of polytraumatized patients: a matched pair analysis

INTRODUCTION

Traumatic lesions of great vessels such as the aorta are life-threatening injuries. There is limited evidence about the influence of traumatic aortic injuries in multiple trauma patients in particular with regard to posttraumatic complications. The aim of this study was to evaluate the influence of blunt thoracic aortic injuries in multiple trauma patients compared to a multiple trauma cohort without this specific injury. In addition, the safety of Thoracic Endovascular Aortic Repair (TEVAR) in multiple trauma patients was analyzed.

MATERIALS AND METHODS

A retrospective study was performed. We included all multiple trauma patients (ISS ≥ 16, age > 14 years) between 2005 and 2014 with (group BTAI) and without (group nBTAI) blunt traumatic aortic injuries who were treated at our level-1 trauma center. Demographic as well as clinical parameters were analyzed including injury pattern, mechanism of injury, posttraumatic complications such as ARDS, multiple organ dysfunction syndrome (MODS) and others. A matched pair analysis was performed by propensity score matching.

RESULTS

In total, 721 patients were enrolled (group BTAI: n = 45; nBTAI: n = 676). In the initial study population, surgical intervention was done in n = 32 (71.1%) patients (TEVAR: n = 25; 78.1%), there was an increased AIS_Chest and overall injury severity in group BTAI with associated significantly more posttraumatic complications in group BTAI. The matched pair analysis consisted of 42 patients per group. Beside an increased ventilation time, no significant differences were evident after the matching process. There was a trend to increased risk for SIRS using binary logistic regression analysis.

CONCLUSIONS

Multiple trauma patients with blunt thoracic aortic injuries who are treated at a level-1 trauma center show a comparable outcome matched to their counterparts without aortic injuries. Our study confirms that using TEVAR in polytraumatized patients is a safe procedure. In all patients treated with TEVAR, there were no procedure-related complications, especially no neurological deficit.

Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis

BACKGROUND

The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM.

METHODS

The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests.

RESULTS

A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR.

CONCLUSIONS

Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Case Report of Traumatic Aortic Disruption: A Lethal Injury Requiring Rapid and Accurate Diagnosis to Lower Mortality

Traumatic aortic disruption is an uncommon but frequently emphasised condition in trauma management in the emergency department. We report a case in which a middle aged woman was hit by a moving vehicle, sustaining multiple severe injuries. Multidetector computed tomography revealed an unexpected but potentially fatal condition – traumatic aortic disruption. A pseudoaneurysm was detected over the aortic arch. In view of the multiple trauma, she was put on conservative treatment. Traumatic aortic disruption should be borne in mind during the emergency evaluation and management of unstable trauma victims, especially those with significant trauma mechanisms. Radiological evaluation plays an important diagnostic role.

The evolution of care improves outcome in blunt thoracic aortic injury: A Western Trauma Association multicenter study

BACKGROUND

The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular aortic repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI.

METHODS

Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between January 1, 2006, and June 30, 2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome.

RESULTS

We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). Thoracic endovascular aortic repair and open repair groups had similar Injury Severity Scale score, chest Abbreviated Injury Scale score, Trauma and Injury Severity Score, and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}, 19-51]; TEVAR: 46 [IQR, 28-60]; p < 0.007), zone of aortic injury (p < 0.001), and grade of aortic injury (open: 6 [IQR, 4-6]; TEVAR: 2 [IQR, 2-4]; p < 0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%; p = 0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%.

CONCLUSIONS

The mortality of BTAI continues to decrease. Thoracic endovascular aortic repair, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in computed tomography imaging in follow-up of TEVAR is warranted.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Blunt chest trauma: a clinical chameleon

The incidence of blunt chest trauma (BCT) is greater than 15% of all trauma admissions to the emergency departments worldwide and is the second leading cause of death after head injury in motor vehicle accidents. The mortality due to BCT is inhomogeneously described ranging from 9% to 60%. BCT is commonly caused by a sudden high-speed deceleration trauma to the anterior chest, leading to a compression of the thorax. All thoracic structures might be injured as a result of the trauma. Complex cardiac arrhythmia, heart murmurs, hypotension, angina-like chest pain, respiratory insufficiency or distention of the jugular veins may indicate potential cardiac injury. However, on admission to emergency departments symptoms might be missing or may not be clearly associated with the injury. Accurate diagnostics and early management in order to prevent serious complications and death are essential for patients suffering a BCT. Optimal initial diagnostics includes echocardiography or CT, Holter-monitor recordings, serial 12-lead electrocardiography and measurements of cardiac enzymes. Immediate diagnostics leading to the appropriate therapy is essential for saving a patient’s life. The key aspect of the entire management, including diagnostics and treatment of patients with BCT, remains an interdisciplinary team involving cardiologists, cardiothoracic surgeons, imaging radiologists and trauma specialists working in tandem.

Thoracic Trauma: Injuries, Evaluation, and Treatment

Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.