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
|
Crapps JL, Efird J, DuBose JJ, Teixeira PG, Shrestha B, Brown CV. Is Chest X-Ray a Reliable Screening Tool for Blunt Thoracic Aortic Injury? Results from the American Association for the Surgery of Trauma/Aortic Trauma Foundation Prospective Blunt Thoracic Aortic Injury Registry. J Am Coll Surg 2023; 236:1031-1036. [PMID: 36719076 DOI: 10.1097/xcs.0000000000000607] [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: 02/01/2023]
Abstract
BACKGROUND Traditional teaching continues to espouse the value of initial trauma chest x-ray (CXR) as a screening tool for blunt thoracic aortic injury (BTAI). The ability of this modality to yield findings that reliably correlate with grade of injury and need for subsequent treatment, however, requires additional multicenter prospective examination. We hypothesized that CXR is not a reliable screening tool, even at the highest grades of BTAI. STUDY DESIGN The Aortic Trauma Foundation/American Association for the Surgery of Trauma prospective BTAI registry was used to correlate initial CXR findings to the Society for Vascular Surgery injury grade identified with computed tomographic angiography. RESULTS We analyzed 708 confirmed BTAI injuries with recorded CXR findings and subsequent computed tomographic angiography injury characterization from February 2015 to August 2021. The presence of any of the classic CXR findings was observed in only 57.6% (408 of 708) of injuries, with increasing presence correlating with advanced Society for Vascular Surgery BTAI grade (39.1% [75 of 192] of grade 1; 55.6% [50 of 90] of grade 2; 65.2% [227 of 348] of grade 3; and 71.8% [56 of 78] of grade 4). The most consistent single finding identified was widened mediastinum, but this was only present in 27.7% of all confirmed BTAIs and only 47.4% of G4 injuries (7.8%% of grade 1, 23.3%, of grade 2, 35.3% of grade 3, and 47.4% of grade 4). CONCLUSIONS CXR is not a reliable screening tool for the detection of BTAI, even at the highest grades of injury. Further investigations of specific high-risk criteria for screening that incorporate imaging, mechanism, and physiologic findings are warranted.
Collapse
Affiliation(s)
- Joshua L Crapps
- From the University of Texas at Austin Dell Medical School, Austin, TX (Crapps, Efird, DuBose, Teixeira, Brown)
| | - Jessica Efird
- From the University of Texas at Austin Dell Medical School, Austin, TX (Crapps, Efird, DuBose, Teixeira, Brown)
| | - Joseph J DuBose
- From the University of Texas at Austin Dell Medical School, Austin, TX (Crapps, Efird, DuBose, Teixeira, Brown)
| | - Pedro G Teixeira
- From the University of Texas at Austin Dell Medical School, Austin, TX (Crapps, Efird, DuBose, Teixeira, Brown)
| | - Binod Shrestha
- the University of Texas Health Science Center at Houston, Memorial Hermann - Texas Medical Center, Houston, TX (Shrestha)
| | - Carlos Vr Brown
- From the University of Texas at Austin Dell Medical School, Austin, TX (Crapps, Efird, DuBose, Teixeira, Brown)
| |
Collapse
|
3
|
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
|
4
|
Wang L, Wu W, Guo X, Yang Y. The clinical characteristics and surgical treatment for delayed blunt thoracic aortic injury-a case series. J Thorac Dis 2022; 14:4136-4142. [PMID: 36389320 PMCID: PMC9641351 DOI: 10.21037/jtd-22-1359] [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: 09/17/2022] [Accepted: 10/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Delayed thoracic aortic injury (DTAI) induced by left closed rib fractures (RFs) is a clinically rare blunt injury to the thoracic aorta with an insidious onset. DTAI is very prone to missed diagnosis due to the unreliability of using the initial post-injury computed tomography (CT) scan to explicitly detect any signs of an aortic injury, potentially leading to a fatal hemorrhage. Timely diagnosis and treatment are therefore key to preventing such deadly complications. With that said, not all cases of left RFs lead to delayed aortic injuries, so how can surgeons tell which cases are to be culled and focused on? Also, what kinds of treatment should be administered upon detection? METHODS A retrospective analysis was performed on the clinical data of DTAI cases induced by left closed RF that were admitted to our Hospital from June 2015 through June 2020. Injuries to the aortic tunica adventitia or the elastic layer were intraoperatively confirmed. CT scan findings, locations and numbers of RFs, as well as the choices of surgical procedure were reviewed postoperatively. In addition, a literature review was conducted to analyze characteristics shared by similar cases. RESULTS This study included 7 patients treated by our hospital and 8 reported in the literature. The broken ends of RFs causing aortic wall injury (including the tunica adventitia) were all found in the medial to the lateral erector spinae. All patients in our hospital received internal fixation for RFs and thoracoscopic removal of free bone fragments (if any). Concomitant injuries were managed either by simultaneous or staged surgery. CONCLUSIONS For multiple left RFs with the broken ends located in the inside of the lateral erector spinae, the number of fractured ribs ≥4 and a smaller number of fractured ribs with multiple fractures in a single rib are important factors for DTAI. Active surgical intervention is recommended for patients with these important factors. The specific intervention is tailored to each patient's particular needs to eliminate the risk of developing life-threatening thoracic aortic injury (TAI) and rupture.
Collapse
Affiliation(s)
- Lei Wang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, China
| | - Weiming Wu
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiang Guo
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Yang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, China
| |
Collapse
|
5
|
Li L, Lin LY, Lu YQ. Analysis of imaging characteristics of blunt traumatic aortic dissection: an 8-year experience. World J Emerg Med 2022; 13:361-366. [PMID: 36119775 PMCID: PMC9420656 DOI: 10.5847/wjem.j.1920-8642.2022.091] [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] [Received: 03/12/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Traumatic aortic dissection (TAD) has a low incidence but extremely high mortality. It always presents atypical clinical manifestations that are easily missed or misdiagnosed. This study mainly aims to describe the imaging characteristics and management of TAD patients. METHODS A retrospective analysis of 27 blunt TAD patients was performed between 2013 and 2020. Demographic features, imaging characteristics, and management were analyzed. RESULTS Twenty-seven patients with type B aortic dissection (age 56.04±16.07 years, 20 men) were included. Aortic intimal tears were mostly initiated from the aortic isthmus. The sizes of the proximal intimal tears in the greater curvature were larger than those in the lesser curvature (1.78±0.56 cm vs. 1.24±0.52 cm, P=0.031). Compared with those in the control group, the maximum diameters of the aortic arch, thoracic aorta, and abdominal aorta in the TAD patients were all significantly widened (all P<0.050). Multivariate logistic regression analysis showed that the maximum diameter of the thoracic aorta was an independent risk factor for TAD, with a predictive value with an area under the receiver operating characteristic curve (AUC) of 0.673. Finally, 26 patients successfully underwent delayed thoracic endovascular aortic repair (TEVAR), and the remaining one patient was treated conservatively. No progression of aortic dissection or death occurred during the six-month follow-up period. CONCLUSIONS In blunt trauma, the aortic isthmus is the most common site of proximal intimal tears. An accurate diagnosis of TAD requires an overall consideration of medical history and imaging characteristics. Delayed TEVAR might be an effective therapeutic option for TAD.
Collapse
Affiliation(s)
- Li Li
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
| | - Li-ying Lin
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
| | - Yuan-qiang Lu
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
| |
Collapse
|
6
|
Ono S, Tateishi R, Shioya M, Itoda Y, Tsukioka Y, Nakahara Y, Kanemura T. Atypical presentation of isolated traumatic ascending aortic dissection with cardiac tamponade. SAGE Open Med Case Rep 2021; 9:2050313X211060683. [PMID: 34925840 PMCID: PMC8673863 DOI: 10.1177/2050313x211060683] [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: 08/02/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Blunt traumatic aortic injury is a rare but life-threatening condition, usually following high-energy trauma. We present the case of a 79-year-old man who was transferred to a hospital complaining of nausea after being struck on the chest. Computed tomography led to diagnosis of ascending aortic dissection with cardiac tamponade. Emergent ascending aortic replacement was performed successfully and he was discharged home on postoperative day 24 without any complications. The key to early diagnosis of blunt traumatic aortic injury is careful and detailed history-taking. If trauma patients complain of unexplained symptoms, the threshold for conducting computed tomography should be lowered to avoid misdiagnosis or therapeutic delay.
Collapse
Affiliation(s)
- Shunya Ono
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Retsu Tateishi
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Masato Shioya
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Yoshihumi Itoda
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Yusuke Tsukioka
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Yoshinori Nakahara
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| | - Takeyuki Kanemura
- Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan
| |
Collapse
|
7
|
Mohammed AA, Shulaiba FR, Alhety MHI, Al Saadi HSAH, El Yafawi B. Aortic Impingement in Displaced Traumatic Spine Fracture with Complete Spinal Cord Transection: A Case Report. DUBAI MEDICAL JOURNAL 2021. [DOI: 10.1159/000520129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Aortic impingement associated with traumatic thoracic spinal fractures is a rare and potentially lethal complication that creates management challenges in an already complex clinical problem. Traumatic aortic injury is one of the leading causes of death in blunt trauma. Magerl divided thoracic and lumbar fractures into 3 categories; the primary focus of this report, type C fractures, describes rotational injury and is one of the less common types, especially associated with aortic impingement as such. In this case, a young man was admitted following a near-fatal fall resulting in blunt force trauma to the midthoracic region. Emergency CT revealed a type C complete transection at the level of T11 and a grade I aortic injury. Definitive fixation of the spinal injury was delayed in favor of preventing further vascular injury by prioritizing the securing of hemodynamic stability. In traumatic thoracolumbar injuries, blunt traumatic aortic injury is often managed conservatively. However, blunt thoracic aortic injury is one of the leading causes of death from trauma, and each case requires its own case-by-case multidisciplinary management. In this occasion, management of the vascular insult was paramount to ensuring patient survival and favorable outcome.
Collapse
|
8
|
Lepkowsky E, Simcox T, Rogoff H, Barzideh O, Islam S. Is There a Role for CT Pan-Scans in the Initial Workup of Fragility Fracture Patients? Geriatr Orthop Surg Rehabil 2020; 11:2151459320916937. [PMID: 32313714 PMCID: PMC7153176 DOI: 10.1177/2151459320916937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/09/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction: Computed tomography (CT) pan-scans have become increasingly commonplace as part of the initial diagnostic workup for patients sustaining traumatic injuries. They have proven effective in improving diagnostic accuracy in those with high-energy mechanisms of injury. However, the utility of pan-scans in the geriatric population sustaining low-energy traumatic injuries remains unproven. Methods: A retrospective review was conducted of patients who sustained a fragility fracture at a level-1 trauma center over a 15-month period. Radiologist interpretations of any CT pan-scans were reviewed for acute findings, and charts were reviewed for resulting changes in orthopedic and nonorthopedic management. Additionally, mechanism of injury, definitive management, time to surgery, length of stay, level of care at discharge, and demographic data were compared against similar patients who did not receive a pan-scan. Results: Of the 109 patients who underwent a CT pan-scan, 1 (0.92%) had a change in orthopedic treatment. Twelve (11.01%) patients had changes to their nonorthopedic management. In addition, 14 other patients had one or more consultations obtained based on pan-scan results that did not result in any change in management. Discussion: This study found that only 1 of the included patients had a change in orthopedic management and 12 had a change in nonorthopedic management, despite over half of the study population being found to have additional findings. Furthermore, patients who underwent a pan-scan did not have expedited surgical intervention or earlier discharges compared to those who were not pan-scanned. Conclusion: This study demonstrates whole-body CT imaging provides little benefit in geriatric patients who sustain fragility fractures and should be utilized judiciously and in a targeted fashion instead of as a routine part of trauma surgery or emergency department protocol in this patient population. Level of Evidence: Level III Retrospective Study.
Collapse
Affiliation(s)
- Eric Lepkowsky
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Trevor Simcox
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Hunter Rogoff
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Omid Barzideh
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Shahidul Islam
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| |
Collapse
|