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Maier J, Alejandre-Lafont E, von Allmen R, Diezi M, Pietsch U, Germann M. [Blunt thoracic trauma with traumatic aortic injury by dislocated rib fragments]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01433-1. [PMID: 39023754 DOI: 10.1007/s00101-024-01433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/25/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Jürgen Maier
- AIOS, Klinik für Anästhesie, Intensivmedizin, Operationszentrum und Schmerzmedizin, Kantonsspital Münsterlingen, Spitalcampus 1, 8596, Münsterlingen, Schweiz.
| | | | - Regula von Allmen
- Klinik für Gefäßchirurgie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9000, St. Gallen, Schweiz
| | - Maja Diezi
- Klinik für Thoraxchirurgie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9000, St. Gallen, Schweiz
| | - Urs Pietsch
- Klinik für operative Intensivmedizin, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9000, St. Gallen, Schweiz
| | - Manon Germann
- Netzwerk Radiologie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9000, St. Gallen, Schweiz
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Jubouri M, Surkhi AO, Al-Tawil M, Geragotellis A, Abdaljawwad TZI, Qudaih M, Elrayes MIR, Dewi M, Moothathamby T, Hammad A, Mohammed I, Awad WI, D'Oria M, Piffaretti G, Bailey DM, Williams IM, Bashir M. Long-Term Survival and Reintervention Following Thoracic Endovascular Aortic Repair in Blunt Traumatic Thoracic Aortic Injury: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:162-176. [PMID: 39004278 DOI: 10.1016/j.avsg.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI. MATERIAL AND METHODS A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4. RESULTS 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I2 = 70.6%). This was 91% (95% CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I2 = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I2 = 81.7%). CONCLUSIONS Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | | | | | - Mohanad Qudaih
- Faculty of Medicine, Al-Quds University, Jerusalem Palestine
| | - Mohammed I R Elrayes
- Department of Paediatric Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Madlen Dewi
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aya Hammad
- Hull York Medical School, University of York, York, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
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D'Oria M, Jubouri M, Piffaretti G, Franchin M, Lepidi S, Bashir M. Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications, techniques, results, and challenges. Vascular 2024:17085381241254629. [PMID: 38741044 DOI: 10.1177/17085381241254629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities. METHODS We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges. RESULTS Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization. CONCLUSIONS Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Matti Jubouri
- University of York, Hull York Medical School, York, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Marco Franchin
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Health & Education Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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Ntola VC, Hardcastle TC, Nkwanyana NM. Management of vascular injuries on ICU patients: KZN experience. Injury 2024; 55:111418. [PMID: 38336574 DOI: 10.1016/j.injury.2024.111418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/10/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries. METHOD A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet. RESULTS There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively. CONCLUSION The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.
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Affiliation(s)
- V C Ntola
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - T C Hardcastle
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - N M Nkwanyana
- School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
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Rasquinha M, Acharya M, O'Neill R, Szfranek A. Emergency endovascular stent grafting for aortic transection following a shotgun injury. Br J Hosp Med (Lond) 2024; 85:1-2. [PMID: 38300679 DOI: 10.12968/hmed.2023.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Melroy Rasquinha
- Department of Cardiac Surgery, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Metesh Acharya
- Department of Cardiac Surgery, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Richard O'Neill
- Department of Radiology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Adam Szfranek
- Department of Cardiac Surgery, Nottingham University Hospital NHS Trust, Nottingham, UK
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Alzerwi NAN. Effect of the Profit and Teaching Status of Hospitals on the Patterns and Outcomes of Abdominal Aorta and Inferior Vena Cava Injuries after Severe Abdominal Trauma. Emerg Med Int 2023; 2023:5616007. [PMID: 37599812 PMCID: PMC10438973 DOI: 10.1155/2023/5616007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/21/2023] [Accepted: 07/29/2023] [Indexed: 08/22/2023] Open
Abstract
Background The inferior vena cava (IVC) and the abdominal aorta (AA) are two important blood vessels located in the abdomen. The outcomes of such injuries rely heavily on the experience, expertise, and resources available at the hospital where the patient is treated. However, our current understanding of the potential impact of the hospital profit and teaching status on surgical outcomes in the context of traumatic injuries to the IVC and AA remains limited, making it important to investigate the potential association between these hospital characteristics and patient outcomes to enhance the quality of care and optimize treatment strategies. Objective This study aimed to compare demographics, trauma characteristics, and outcomes between nonprofit status (NPSH) and for-profit hospital status (FPSH), as well as among community hospitals (CHs), nonteaching hospitals (NTHs), and university hospitals (UHs), in patients with severe abdominal trauma and abdominal aorta injury (AAI), inferior vena cava injury (IVCI), and both (AAI + IVCI). Methods Demographics, trauma, and outcome measures associated with AAI, IVCI, and AAI + IVCI were compared between the different profit and teaching status groups using NTDB. Multivariate regression was used to identify independent factors associated with death under care (DUC). Results In the 2017 NTDB-RDS, 1,479 patients met the inclusion criteria, resulting in an overall incidence of 0.17% for AAI, IVCI, and AAI + IVCI after severe abdominal trauma. More patients died under care in the FPSH group than in the NPSH group (nonprofit vs. for-profit: 60.3% vs. 47.2%; P < 0.001). The results indicated that FPSH independently affected DUC. NTH had no significant effect on DUC; although the in-hospital complication rate varied with NTH, no independent association was observed. Conclusions The study findings demonstrated that in patients with severe abdominal trauma, including injuries to AAI, IVCI, or both (AAI + IVCI), the profit status of hospitals, rather than the teaching status, had a substantial influence on DUC. Future studies should examine differences in the volume of cases and levels of trauma centers to better understand how to improve patient outcomes in FPSH.
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Affiliation(s)
- Nasser A. N. Alzerwi
- Department of Surgery, College of Medicine, Majmaah University, Ministry of Education, P. O. Box 66, Al-Majmaah 11952, Riyadh, Saudi Arabia
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Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustiniano E. The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg 2023; 36:363-379. [PMID: 37330248 DOI: 10.1053/j.semvascsurg.2023.04.017] [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: 02/26/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.
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Affiliation(s)
- Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Antonio Reda
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Arianna Pignataro
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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dos Reis JMC, Ribeiro FRCDM, Koury A, Melo GDS, de Oliveira MV, Gomes VHGA, dos Santos JVF, Sarquis SG. Traumatic aorta injuries in a rural area: late manifestations and review of therapeutic aspects. J Vasc Bras 2023; 22:e20220014. [PMID: 37346376 PMCID: PMC10281037 DOI: 10.1590/1677-5449.202200142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/05/2023] [Indexed: 06/23/2023] Open
Abstract
Traumatic thoracic aortic injuries (TTAI) are associated with high rates of morbidity and mortality. They are classified according to the extent of damage and computed tomography angiography has the highest sensitivity and specificity for identifying the degree of injury and potential associated lesions. Treatment strategies for TTAI are based on the type and extent of injury and associated lesions. The patient's degree of stability can also help to define the choice of treatment, which can be conventional or endovascular surgery (EVAR) or even conservative management in selected cases. Among patients with adequate vascular anatomy, endovascular surgery is associated with better survival and fewer risks. The objective of this article is to describe a series of four cases followed up at a tertiary service in a Brazilian state that has few centers that provide high complexity care. Endovascular therapy was employed as the preferred method. All four patients had favorable outcomes, with no complications up to discharge, and are currently in outpatient follow-up.
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Affiliation(s)
- José Maciel Caldas dos Reis
- Centro Universitário Metropolitano da Amazônia - UNIFAMAZ, Belém, PA, Brasil.
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
| | | | - Adib Koury
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
| | | | | | | | - José Victor Figueiredo dos Santos
- Centro Universitário Metropolitano da Amazônia - UNIFAMAZ, Belém, PA, Brasil.
- Hospital de Clínicas Gaspar Vianna - HCGV, Belém, PA, Brasil.
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Johnson P, Anderson R, Gamble C, van Bogaert E, Joshi J. Traumatic aortic injury from pellet gun: A case report. Radiol Case Rep 2023; 18:1368-1371. [PMID: 36747590 PMCID: PMC9898574 DOI: 10.1016/j.radcr.2022.10.014] [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: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023] Open
Abstract
Acute traumatic aortic injuries are of the most lethal sequelae of penetrating thoracic injuries and require rapid detection and management. The American College of Radiology currently recommends the use of noncontrast CT, followed by computed tomography angiography (CTA) as the first-line imaging modalities when traumatic aortic injury is suspected. Direct signs of aortic injury on CTA include pseudoaneurysm, focal contour abnormality, intimal flap, intramural hematoma, an abrupt change in aortic caliber, and contrast extravasation. Aortic pseudoaneurysms are most often caused by blunt or penetrating trauma that results in damage to the vessel wall, turbulent blood flow, and formation of a surrounding hematoma contained by a wall of products from the clotting cascade. This wall is weaker than those of a true aneurysm and will ultimately rupture over time if not repaired. Traumatic aortic pseudoaneurysms are preferably treated by thoracic endovascular aortic repair using a prosthetic stent graft. Here, we present a 44-yearold female with a history of homelessness, polysubstance use disorder, and HIV who presented to the emergency department after being found down. She reported being shot by a pellet gun, and physical examination revealed a penetrating left-sided chest wound that appeared to be several days old. A STAT CTA was obtained and revealed a hemopneumothorax and possible thoracic aortic pseudoaneurysm. A left-sided chest tube was placed and the patient underwent thoracic endovascular aortic repair through right femoral arterial access and tolerated the procedure well. The patient was placed on daily aspirin postoperatively and discharged on post-op day 5.
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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.
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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
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Al-Thani H, Hakim S, Asim M, Basharat K, El-Menyar A. Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital. Eur J Trauma Emerg Surg 2022; 48:4079-4091. [PMID: 35286404 PMCID: PMC9532277 DOI: 10.1007/s00068-022-01930-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center. METHODS We conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan-Meier curve and Cox regression analysis were performed for the outcome. RESULTS Eighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I-IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I-II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001). CONCLUSIONS BTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.
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Affiliation(s)
- Hassan Al-Thani
- Trauma and Vascular Surgery Section, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Suhail Hakim
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
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