1
|
Omar A, Winkelmann M, Liodakis E, Clausen JD, Graulich T, Omar M, Krettek C, Macke C. Applicability of Anatomic and Physiologic Scoring Systems for the Prediction of Outcome in Polytraumatized Patients with Blunt Aortic Injuries. Diagnostics (Basel) 2021; 11:diagnostics11112156. [PMID: 34829503 PMCID: PMC8617692 DOI: 10.3390/diagnostics11112156] [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: 09/17/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Most patients with blunt aortic injuries, who arrive alive in a clinic, suffer from traumatic pseudoaneurysms. Due to modern treatments, the perioperative mortality has significantly decreased. Therefore, it is unclear how exact the prediction of commonly used scoring systems of the outcome is. Methods: We analyzed data on 65 polytraumatized patients with blunt aortic injuries. The following scores were calculated: injury severity score (ISS), new injury severity score (NISS), trauma and injury severity score (TRISS), revised trauma score coded (RTSc) and acute physiology and chronic health evaluation II (APACHE II). Subsequently, their predictive value was evaluated using Spearman´s and Kendall´s correlation analysis, logistic regression and receiver operating characteristics (ROC) curves. Results: A proportion of 83% of the patients suffered from a thoracic aortic rupture or rupture with concomitant aortic wall dissection (54/65). The overall mortality was 24.6% (16/65). The sensitivity and specificity were calculated as the area under the receiver operating curves (AUC): NISS 0.812, ISS 0.791, APACHE II 0.884, RTSc 0.679 and TRISS 0.761. Logistic regression showed a slightly higher specificity to anatomical scoring systems (ISS 0.959, NISS 0.980, TRISS 0.957, APACHE II 0.938). The sensitivity was highest in the APACHE II with 0.545. Sensitivity and specificity for the RTSc were not significant. Conclusion: The predictive abilities of all scoring systems were very limited. All scoring systems, except the RTSc, had a high specificity but a low sensitivity. In our study population, the RTSc was not applicable. The APACHE II was the most sensitive score for mortality. Anatomical scoring systems showed a positive correlation with the amount of transfused blood products.
Collapse
Affiliation(s)
- Alexander Omar
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
- Bundeswehr Joint Medical Service, 26384 Wilhelmshaven, Germany
| | - Marcel Winkelmann
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Emmanouil Liodakis
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Jan-Dierk Clausen
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Tilman Graulich
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Mohamed Omar
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Christian Krettek
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
| | - Christian Macke
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany; (A.O.); (M.W.); (E.L.); (J.-D.C.); (T.G.); (M.O.); (C.K.)
- Correspondence:
| |
Collapse
|
2
|
A systematic review and meta-analysis of endovascular versus open surgical repair for the traumatic ruptured thoracic aorta. J Vasc Surg 2020; 71:270-282. [DOI: 10.1016/j.jvs.2019.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 05/08/2019] [Indexed: 01/16/2023]
|
3
|
Limited influence of blunt aortic injuries on the outcome of polytraumatized patients: a matched pair analysis. Arch Orthop Trauma Surg 2018; 138:211-218. [PMID: 29143168 DOI: 10.1007/s00402-017-2842-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Indexed: 10/18/2022]
Abstract
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 AISChest 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.
Collapse
|
4
|
Rousseau H, Elaassar O, Marcheix B, Cron C, Chabbert V, Combelles S, Dambrin C, Leobon B, Moreno R, Otal P, Auriol J. The Role of Stent-Grafts in the Management of Aortic Trauma. Cardiovasc Intervent Radiol 2011; 35:2-14. [DOI: 10.1007/s00270-011-0135-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 02/15/2011] [Indexed: 11/28/2022]
|
5
|
Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010; 55:986-1001. [PMID: 20137879 DOI: 10.1016/j.jacc.2009.11.047] [Citation(s) in RCA: 285] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 11/12/2009] [Accepted: 11/19/2009] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.
Collapse
|
6
|
Ryu YG, Choo SJ, Lim JY, Yoon HK, Chung CH. Hybrid procedure for a traumatic aortic rupture consisting of endovascular repair and minimally invasive arch vessel transposition without sternotomy. J Korean Med Sci 2010; 25:142-4. [PMID: 20052360 PMCID: PMC2800019 DOI: 10.3346/jkms.2010.25.1.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 07/28/2008] [Indexed: 11/20/2022] Open
Abstract
Emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri-procedural mortality rate. Endovascular stent-grafting, as a less invasive procedure, has shown encouraging results. This report describes a patient with a short landing zone, who was treated by transposing the supra-aortic branch without sternotomy, followed by covered stent-grafting with an extended proximal bare portion to enhance fixation.
Collapse
Affiliation(s)
- Yang Gi Ryu
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University Medical Center, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hyun Ki Yoon
- Department of Interventional Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Karmy-Jones R, Teso D, Jackson N, Ferigno L, Bloch R. Endovascular approach to acute aortic trauma. World J Radiol 2009; 1:50-62. [PMID: 21160721 PMCID: PMC2998886 DOI: 10.4329/wjr.v1.i1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 12/18/2009] [Accepted: 12/21/2009] [Indexed: 02/06/2023] Open
Abstract
Traumatic thoracic aortic injury remains a major cause of death following motor vehicle accidents. Endovascular approaches have begun to supersede open repair, offering the hope of reduced morbidity and mortality. The available endovascular technology is associated with specific anatomic considerations and complications. This paper will review the current status of endovascular management of traumatic thoracic aortic injuries.
Collapse
|
8
|
Akowuah E, Angelini G, Bryan AJ. Open versus endovascular repair of traumatic aortic rupture: A systematic review. J Thorac Cardiovasc Surg 2009; 138:768-9. [DOI: 10.1016/j.jtcvs.2008.05.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 04/25/2008] [Accepted: 05/16/2008] [Indexed: 11/30/2022]
|
9
|
Karmy-Jones R, Jackson N, Long W, Simeone A. Current management of traumatic rupture of the descending thoracic aorta. Curr Cardiol Rev 2009; 5:187-95. [PMID: 20676277 PMCID: PMC2822141 DOI: 10.2174/157340309788970324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 01/20/2009] [Accepted: 01/21/2009] [Indexed: 11/22/2022] Open
Abstract
Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.
Collapse
Affiliation(s)
- Riyad Karmy-Jones
- Divisions of Thoracic-Vascular and Trauma Surgery, Southwest Washington Medical Center, Vancouver WA, USA
| | | | | | | |
Collapse
|
10
|
Sunder-Plassmann L, Oberhuber A, Mühling B, Lang G, Schelzig H, Bischoff G, Orend KH, Rasche V. Endovaskuläre Versorgung der traumatischen Aortenruptur im Akutstadium. GEFÄSSCHIRURGIE 2009. [DOI: 10.1007/s00772-009-0671-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
11
|
[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. Anaesthesist 2009; 57:782-93. [PMID: 18463834 DOI: 10.1007/s00101-008-1375-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.
Collapse
|
12
|
Xenos ES, Abedi NN, Davenport DL, Minion DJ, Hamdallah O, Sorial EE, Endean ED. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 2008; 48:1343-51. [DOI: 10.1016/j.jvs.2008.04.060] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/25/2008] [Accepted: 04/25/2008] [Indexed: 10/21/2022]
|
13
|
Lin PH, Huynh TT, Kougias P, Wall MJ, Coselli JS, Mattox KL. Endovascular Repair of Traumatic Thoracic Aortic Injuries: A Critical Appraisal. Asian Cardiovasc Thorac Ann 2008; 16:337-45. [DOI: 10.1177/021849230801600419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.
Collapse
Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Tam T Huynh
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Panagiotis Kougias
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Mathew J Wall
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Texas Heart Institute at St. Luke's Episcopal Hospital
| | - Kenneth L Mattox
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
| |
Collapse
|
14
|
Pitton MB, Herber S, Schmiedt W, Neufang A, Dorweiler B, Düber C. Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies. Cardiovasc Intervent Radiol 2007; 31:23-35. [PMID: 17943352 DOI: 10.1007/s00270-007-9175-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 07/12/2007] [Accepted: 08/29/2007] [Indexed: 11/30/2022]
Affiliation(s)
- M B Pitton
- Department of Diagnostic and Interventional Radiology, University Hospital of Mainz, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | | | | | | | | | | |
Collapse
|
15
|
Schumacher H, Böckler D, von Tengg-Kobligk H, Allenberg JR. Acute Traumatic Aortic Tear: Open Versus Stent-graft Repair. Semin Vasc Surg 2006; 19:48-59. [PMID: 16533692 DOI: 10.1053/j.semvascsurg.2005.11.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute traumatic aortic tear (ATAT) is the second most common cause of deaths in trauma patients (about 8,000 deaths/year in the USA). Due to circumferential aortic disruption, up to 90% die at the scene. Responsible trauma mechanisms are: penetrating (gunshot/stab wounds), iatrogenic (interventional catheterization) and, most frequently, blunt chest trauma (high-speed motor vehicles, falls from heights, crushes, explosions) resulting in injury at the aortic isthmus region (loco typico, about 90%). Severe multiple system injuries (polytrauma), especially to intracranial and intraabdominal organs, are characteristic and prognostically predicitive. Immediate transthoracic open repair of ATAT has a mortality risk of 8% to 33% and paraplegia risk of 2% to 26%. Contrast enhanced CT scan has replaced the classical angiography as the diagnostic tool of choice. Patients with life-threatening multisystem injuries are scheduled for delayed repair after initial stabilization. Currently, the use of endovascular stent-grafts (EVAR) is being investigated. Our personal series confirms that EVAR for ATAT is a viable alternative to open repair while minimizing the morbidity and mortality of the open procedure and having a limited impact on trauma destabilization. The assessment of long-term durability of EVAR is one of the key issues to consider EVAR as the first choice of treatment.
Collapse
Affiliation(s)
- Hardy Schumacher
- Department of Vascular and Endovascular Surgery, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.
| | | | | | | |
Collapse
|
16
|
Stahel PF, Schneider P, Buhr HJ, Kruschewski M. [Emergency management of thoracic trauma]. DER ORTHOPADE 2005; 34:865-79. [PMID: 16044335 DOI: 10.1007/s00132-005-0845-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.
Collapse
Affiliation(s)
- P F Stahel
- Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
| | | | | | | |
Collapse
|