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Lu E, Dubose J, Venkatesan M, Wang ZP, Starnes BW, Saqib NU, Miller CC, Azizzadeh A, Chou EL. Using machine learning to predict outcomes of patients with blunt traumatic aortic injuries. J Trauma Acute Care Surg 2024; 97:258-265. [PMID: 38548696 DOI: 10.1097/ta.0000000000004322] [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: 07/26/2024]
Abstract
BACKGROUND The optimal management of blunt thoracic aortic injury (BTAI) remains controversial, with experienced centers offering therapy ranging from medical management to TEVAR. We investigated the utility of a machine learning (ML) algorithm to develop a prognostic model of risk factors on mortality in patients with BTAI. METHODS The Aortic Trauma Foundation registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. A STREAMLINE (A Simple, Transparent, End-To-End Automated Machine Learning Pipeline Facilitating Data Analysis and Algorithm Comparison) model as well as logistic regression (LR) analysis with imputation using chained equations was developed and compared. RESULTS From a total of 1018 patients in the registry, 702 patients were included in the final analysis. Of the 258 (37%) patients who were medically managed, 44 (17%) died during admission, 14 (5.4%) of which were aortic related deaths. Four hundred forty-four (63%) patients underwent TEVAR and 343 of which underwent TEVAR within 24 hours of admission. Among TEVAR patients, 39 (8.8%) patients died and 7 (1.6%) had aortic related deaths ( Table 1 ). Comparison of the STREAMLINE and LR model showed no significant difference in ROC curves and high AUCs of 0.869 (95% confidence interval, 0.813-0.925) and 0.840 (95% confidence interval, 0.779-0.900) respectively in predicting in-hospital mortality. Unexpectedly, however, the variables prioritized in each model differed between models. The top 3 variables identified from the LR model were similar to that from existing literature. The STREAMLINE model, however, prioritized location of the injury along the lesser curve, age and aortic injury grade. CONCLUSION Machine learning provides insight on prioritization of variables not typically identified in standard multivariable logistic regression. Further investigation and validation in other aortic injury cohorts are needed to delineate the utility of ML models. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Eileen Lu
- From the Division of Vascular Surgery (E.L., A.A., E.L.C.), Cedars-Sinai Medical Center, Los Angeles, California; Department of Surgery (J.D.), University of Texas at Austin Dell Medical School, Austin, Texas; Department of Computational Biomedicine (M.V., Z.P.W.), Cedars-Sinai Medical Center, West Hollywood, California; Division of Vascular Surgery, Department of Surgery (B.W.S.), University of Washington, Seattle, Washington; and Department of Cardiothoracic and Vascular Surgery (N.U.S., C.C.M.), University of Texas Health Science Center, Houston, Texas
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Liu Y, Sun L, Wang Q, Xiang B, Cai H, Xie Y, Li M, Xiang H. Delayed endovascular repair for traumatic aortic pseudoaneurysms: experience from an Asian single center. J Cardiothorac Surg 2023; 18:19. [PMID: 36631825 PMCID: PMC9835260 DOI: 10.1186/s13019-022-02078-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/10/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Traumatic aortic pseudoaneurysms (PSAs) classified as grade III aortic injuries are conventionally repaired as procedural emergencies, generally within 24 h of arrival. These patients typically require adequate resuscitation and treatment of multiple traumatic injuries, which complicate optimal management strategies of aortic PSAs. This study reviews the experience of an Asian single center to evaluate the efficacy and safety of delayed (> 24 h) endovascular repair for PSAs. METHODS Twenty-seven patients with blunt aortic injury (BTAI) were brought to our institution between February 2014 and May 2020. Patients with other grades of aortic injuries (grade I, II, or IV) were excluded from the study, and the remaining patients with grade III aortic injuries were placed into the early (< 24 h) and delayed (> 24 h) groups according to the timing of repair. Medical records and follow-up computed tomography (CT) scans were reviewed to document the outcomes of the procedures. Primary outcomes included mortality and complications. RESULTS During this period, there were 14 patients (13 males and 1 females) with aortic PSAs, and each patient received thoracic endovascular aortic repair (TEVAR). Of these 14 patients, 1 underwent emergent TEVAR, and 13 underwent delayed repair (median 7 days, range, 3-14 days). Over a period of 8 years, the overall survival of our series was 100%. No paraplegia, stroke, ischemia of limb or other serious procedural complications were observed during the duration of follow-up. CONCLUSION The experience of our center indicates that delayed repair for selected PSAs could be permissible, which enables a repair in more controlled circumstances.
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Affiliation(s)
- Yuzhou Liu
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Lin Sun
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Qing Wang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Bin Xiang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Huangxing Cai
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Yong Xie
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Muzi Li
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Hua Xiang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
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Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury. Ann Vasc Surg 2022; 84:195-200. [PMID: 35247536 DOI: 10.1016/j.avsg.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.
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Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology 2022; 73:497-507. [DOI: 10.1177/00033197211052131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ranjan Dahal
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Alan H. Tyroch
- Department of Surgery, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
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Lee J, Ye J, Lee J, Kim S, Choi H, Kim Y, Yoon S, Sul Y, Choi J. Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution. Int J Crit Illn Inj Sci 2022; 12:101-105. [PMID: 35845121 PMCID: PMC9285127 DOI: 10.4103/ijciis.ijciis_89_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/08/2021] [Accepted: 01/01/2022] [Indexed: 12/04/2022] Open
Abstract
Background: We aimed to investigate the outcomes after delayed management of ≥ Grade II blunt traumatic thoracic aortic injury (BTAI). Methods: Between January 2005 and December 2019, we retrospectively reviewed the medical records of 21 patients with ≥ Grade II thoracic aortic injury resulting from blunt trauma. Twelve patients underwent observation for the injury, whereas nine patients were transferred immediately after the diagnosis. Patients were divided into a nonoperative management group (n = 7) and delayed repair group (n = 5) based on whether they underwent thoracic endovascular aneurysm repair or surgery. Results: The most common dissection type was DeBakey classification IIIa (n = 9). Five patients underwent delayed surgery (including aneurysm repair), with observation periods ranging from 1 day to 36 months. The delayed repair group exhibited higher injury severity scores than the nonoperative management group (n = 7). The nonoperative management group was followed-up with blood pressure management without a change in status for a period ranging from 3 to 96 months. Conclusions: Our findings indicated that conservative management may be appropriate for select patients with Grade II/III BTAI, especially those exhibiting hemodynamic stability with anti-impulse therapy and minimally sized pseudoaneurysms. However, further studies are required to identify the risk factors for injury progression and long-term outcomes.
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Arbabi CN, DuBose J, Starnes BW, Saqib N, Quiroga E, Miller C, Azizzadeh A. Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry. J Vasc Surg 2021; 75:930-938. [PMID: 34606963 DOI: 10.1016/j.jvs.2021.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/10/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy. METHODS The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (<6 vs ≥6 hours) or urgent (<24 vs ≥24 hours) intervals. RESULTS A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (<6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (<24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke. CONCLUSIONS In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.
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Affiliation(s)
- Cassra N Arbabi
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Joseph DuBose
- Division of Vascular Surgery, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Md
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Naveed Saqib
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Charles Miller
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Houston, Tex
| | - Ali Azizzadeh
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
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Quiroga E, Levitt MR, Czerwonko ME, Starnes BW, Tran NT, Singh N. Management of Moderate Blunt Thoracic Aortic Injuries in Patients with Intracranial Hemorrhage. Ann Vasc Surg 2020; 73:15-21. [PMID: 33359706 DOI: 10.1016/j.avsg.2020.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/06/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
| | - Michael R Levitt
- Departments of Neurological Surgery, Seattle, WA; Departments of Radiology, Seattle, WA; Departments of Mechanical Engineering, Seattle, WA; Departments of Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA
| | - Matias E Czerwonko
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nam T Tran
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
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Zambetti BR, Huang DD, Lewis RH, Fischer PE, Croce MA, Magnotti LJ. Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury. J Am Coll Surg 2020; 232:416-422. [PMID: 33348014 DOI: 10.1016/j.jamcollsurg.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Dih-Dih Huang
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Richard H Lewis
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Peter E Fischer
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN.
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D'Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, Trimarchi S. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:681-696. [PMID: 32964899 DOI: 10.23736/s0021-9509.20.11580-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
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Affiliation(s)
- Ilenia D'Alessio
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Bissacco
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierantonio Rimoldi
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno Palmieri
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Management and In-hospital Mortality of 2235 Patients With a Traumatic Intimal Tear of the Thoracic Aorta. Ann Surg 2020; 276:186-192. [DOI: 10.1097/sla.0000000000004415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hundersmarck D, van der Vliet QMJ, Winterink LM, Leenen LPH, van Herwaarden JA, Hazenberg CEVB, Hietbrink F. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg 2020; 48:1961-1973. [PMID: 32632630 PMCID: PMC9192473 DOI: 10.1007/s00068-020-01432-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Quirine M. J. van der Vliet
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Lotte M. Winterink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | | | | | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
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Jadidi M, Habibnezhad M, Anttila E, Maleckis K, Desyatova A, MacTaggart J, Kamenskiy A. Mechanical and structural changes in human thoracic aortas with age. Acta Biomater 2020; 103:172-188. [PMID: 31877371 DOI: 10.1016/j.actbio.2019.12.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 12/22/2022]
Abstract
Aortic mechanical and structural characteristics have profound effects on pathophysiology, but many aspects of physiologic stress-stretch state and intramural changes due to aging remain poorly understood in human tissues. While difficult to assess in vivo due to residual stresses and pre-stretch, physiologic stress-stretch characteristics can be calculated using experimentally-measured mechanical properties and constitutive modeling. Mechanical properties of 76 human descending thoracic aortas (TA) from 13 to 78-year-old donors (mean age 51±18 years) were measured using multi-ratio planar biaxial extension. Constitutive parameters were derived for aortas in 7 age groups, and the physiologic stress-stretch state was calculated. Intramural characteristics were quantified from histological images and related to aortic morphometry and mechanics. TA stiffness increased with age, and aortas became more nonlinear and anisotropic. Systolic and diastolic elastic energy available for pulsation decreased with age from 30 to 8 kPa and from 18 to 5 kPa, respectively. Cardiac cycle circumferential stretch dropped from 1.14 to 1.04, and circumferential and longitudinal physiologic stresses decreased with age from 90 to 72 kPa and from 90 to 17 kPa, respectively. Aortic wall thickness and radii increased with age, while the density of elastin in the tunica media decreased. The number of elastic lamellae and circumferential physiologic stress per lamellae unit remained constant with age at 102±10 and 0.85±0.04 kPa, respectively. Characterization of mechanical, physiological, and structural features in human aortas of different ages can help understand aortic pathology, inform the development of animal models that simulate human aging, and assist with designing devices for open and endovascular aortic repairs. STATEMENT OF SIGNIFICANCE: This manuscript describes mechanical and structural changes occurring in human thoracic aortas with age, and presents material parameters for 4 commonly used constitutive models. Presented data can help better understand aortic pathology, inform the development of animal models that simulate human aging, and assist with designing devices for open and endovascular aortic repairs.
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Affiliation(s)
- Majid Jadidi
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Mahmoud Habibnezhad
- Department of Computer Science, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Eric Anttila
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Kaspars Maleckis
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, United States; Department of Biomechanics, University of Nebraska Omaha, Omaha, NE, United States
| | - Anastasia Desyatova
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, United States; Department of Biomechanics, University of Nebraska Omaha, Omaha, NE, United States
| | - Jason MacTaggart
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, United States
| | - Alexey Kamenskiy
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, United States; Department of Biomechanics, University of Nebraska Omaha, Omaha, NE, United States.
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Pu X, Huang XY, Huang LJ. Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience. Chin J Traumatol 2020; 23:15-19. [PMID: 32057561 PMCID: PMC7049641 DOI: 10.1016/j.cjtee.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/18/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair (TEVAR) in patients with traumatic blunt aortic injury in our single-center. METHODS From January 2014 to December 2018, a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center. Their clinical data such as demographics, operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software. Continuous variables were expressed as mean and standard deviation or median and interquartile range. Categorical variables are expressed as the numbers and percentages of patients. RESULTS The median age of the patients was 37 years, and 76 (85.4%) were males. All the patients were involved in violent accidents and combined with associated injuries. Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR, with a 100% technique success. The mean time interval from admission to operating room was (90.1 ± 18.7) min, and the mean procedure time was (54.6 ± 11.9) min. Eighty (92.0%) patients were operated on under local anesthesia, while other 7 (8.0%) patients were under general anesthesia. Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels. A total of 98 aortic covered stent grafts were deployed, of which 11 patients used two stent grafts (all in dissection cases). The length of the stent was (177.5 ± 24.6) mm. The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was (24.9 ± 2.4) mm, the proximal diameter of the covered stent was (30.5 ± 2.6) mm, and the oversize rate of proximal site was (22.7 ± 4.0)%. The proximal landing zone length was (14.1 ± 5.5) mm. The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients. No blood flow reconstruction was performed. The overall aortic-related mortality was 2.25% (2/89). Among 87 patients, the median follow-up time was 24 months. Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm, hematoma or endoleak. One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion. Neither late death, nor neurological or other complications occurred. CONCLUSION Emergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries. Long-term results remain to be further followed.
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Soong TK, Wee IJY, Tseng FS, Syn N, Choong AMTL. A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients. J Vasc Surg 2020; 70:941-953.e13. [PMID: 31445650 DOI: 10.1016/j.jvs.2018.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 12/23/2018] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Tse Kiat Soong
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ian J Y Wee
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Fan Shuen Tseng
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew M T L Choong
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Cardiovascular Research Institute, National University of Singapore, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Vascular Surgery, National University Heart Centre, Singapore.
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Abstract
ZusammenfassungVerkehrsunfälle 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.
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Kaneyuki D, Asakura T, Iguchi A, Yoshitake A, Tokunaga C, Tochii M, Nakajima H. Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience. Eur J Cardiothorac Surg 2019; 56:5309042. [PMID: 30753390 DOI: 10.1093/ejcts/ezz023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/10/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear. METHODS From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter. RESULTS The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up. CONCLUSIONS This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.
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Affiliation(s)
- Daisuke Kaneyuki
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Toshihisa Asakura
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Atsushi Iguchi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Akihiro Yoshitake
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Chiho Tokunaga
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Masato Tochii
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Hiroyuki Nakajima
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
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Ma DS, Kim SJ, Joo S, Hyun SY, Jeon YB. Delayed Surgical Management of Traumatic Pseudoaneurysm of the Ascending Aorta in Multiple Trauma. JOURNAL OF TRAUMA AND INJURY 2018. [DOI: 10.20408/jti.2018.31.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Dae Sung Ma
- Department of Trauma Surgery, Trauma Center, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Jin Kim
- Department of Trauma Surgery, Trauma Center, Gachon University Gil Medical Center, Incheon, Korea
| | - Seok Joo
- Department of Trauma Surgery, Trauma Center, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Youl Hyun
- Department of Trauma Surgery, Trauma Center, Gachon University Gil Medical Center, Incheon, Korea
| | - Yang Bin Jeon
- Department of Trauma Surgery, Trauma Center, Gachon University Gil Medical Center, Incheon, Korea
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Imaging of Acute Traumatic Aortic Injury. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0278-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Harris DG, Rabin J, Crawford RS, Klyushnenkova EN, Drucker CB, Chen H, Scalea TM, Diaz JJ. Incidence and outcomes of thoracic aortic injuries with regionalized care in a mature trauma system. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408617738811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction Thoracic aortic injury is a leading cause of death after blunt trauma, but the effect of trauma system organization on outcomes is undefined. This was an analysis of thoracic aortic injury in a state with a comprehensive trauma system. Methods This was a retrospective study of thoracic aortic injury in Maryland between 2009 and 2014 using a statewide inpatient admission database. Presence of thoracic aortic injury and open or endovascular aortic interventions were identified by International Classification of Diseases version 9 codes. Patients were compared by admitting hospital status, categorized as Level I or non-Level I trauma centers. Outcomes were overall inpatient mortality and death after aortic repair. Results Of 774,211 injured patients, 168 (0.02%) had thoracic aortic injury. Patients with thoracic aortic injury were younger, more often male, and were more severely injured than patients without thoracic aortic injury. The majority of patients (136, 81%) were admitted to Level I trauma centers; Level I and non-Level I patients had similar characteristics. Most patients (110, 65%) were managed non-operatively, but patients admitted to Level I facilities were more likely to undergo aortic repair. Overall and post-operative mortality rates were lower at Level I hospitals (22% versus 31% and 6% versus 17%, respectively), but these differences did not reach statistical significance. Conclusion This novel analysis indicates thoracic aortic injury management in Maryland is highly concentrated at Level I trauma centers, which was associated with mortality below previously reported national rates. Although limited by small sample size, these findings suggest a benefit to regionalized care for patients with thoracic aortic injury and support transfer to high-volume facilities for definitive management.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Robert S Crawford
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, USA
| | - Elena N Klyushnenkova
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Charles B Drucker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Hegang Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Jose J Diaz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
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Abstract
Blunt thoracic aortic injury remains a major cause of prehospital deaths. For patients who reach the hospital alive, diagnosis and management have undergone dramatic changes over the last 50 years. Computed tomography scanning is the imaging modality of choice for injury diagnosis and repair planning. Medical management with antihypertensives dramatically decreases the risk of rupture, allowing for delayed repair, while abnormal physiology and more immediately life-threatening injuries can be addressed. Endovascular techniques and endograft technology have reduced significantly the risks associated with repair. However, the incidence of late complications associated with the devices currently available is not known.
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Affiliation(s)
- Marc D Trust
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1501 Red River Street, Austin, TX 78712, USA
| | - Pedro G R Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1501 Red River Street, Austin, TX 78712, USA.
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Abstract
The elderly population is rapidly increasing in number. Therefore, geriatric trauma is becoming more prevalent. All practitioners caring for geriatric trauma patients should be familiar with the structural and functional changes naturally occurring in the aging heart, as well as common preexisting cardiac diseases in the geriatric population. Identification of the shock state related to cardiac dysfunction and targeted assessment of perfusion and resuscitation are important when managing elderly patients. Finally, management of cardiac dysfunction in the trauma patient includes an appreciation of the inherent effects of trauma on cardiac function.
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Martin C, Thony F, Rodiere M, Bouzat P, Lavagne P, Durand M, Chavanon O. Long-term results following emergency stent graft repair for traumatic rupture of the aortic isthmus†. Eur J Cardiothorac Surg 2017; 51:767-772. [DOI: 10.1093/ejcts/ezw369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/10/2016] [Indexed: 01/16/2023] Open
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Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64:1580-1586. [DOI: 10.1016/j.jvs.2016.05.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
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Harris DG, Rabin J, Starnes BW, Khoynezhad A, Conway RG, Taylor BS, Toursavadkohi S, Crawford RS. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg 2016; 64:500-505. [DOI: 10.1016/j.jvs.2015.12.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/19/2015] [Indexed: 10/21/2022]
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Harris DG, Rabin J, Bhardwaj A, June AS, Oates CP, Garrido D, Toursavadkohi S, Khoynezhad A, Crawford RS. Nonoperative Management of Traumatic Aortic Pseudoaneurysms. Ann Vasc Surg 2016; 35:75-81. [PMID: 27263820 DOI: 10.1016/j.avsg.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current blunt thoracic aortic injury (BTAI) guidelines recommend early repair of traumatic pseudoaneurysms (PSAs) due to risk for subsequent aortic rupture. Recent analyses indicate that early repair is required only in the setting of high-risk features, while delayed repair is safe and associated with lower morbidity and mortality in appropriately selected patients. To evaluate the appropriate indications for nonoperative management (NOM) of traumatic PSAs, we performed a systematic review of studies reporting outcomes for this management strategy. We hypothesized that NOM is safe in appropriately selected patients with traumatic aortic PSAs. METHODS English language single- and multi-institutional series reporting NOM of traumatic thoracic aortic PSAs were identified by systematic literature search and review. A descriptive analysis was performed of NOM, with stratification by lesion size and patient follow-up. The primary outcomes were late aortic intervention, aortic-related death, and all-cause mortality. RESULTS Eighteen studies, which included 937 patients with traumatic PSAs, were analyzed. One hundred ninety-one patients were managed nonoperatively. The primary indication for NOM was prohibitive risk for aortic repair due to severe comorbidities or concurrent injuries. Where reported, PSAs with <50% circumferential involvement accounted for 88% of lesions selected for NOM. Late interventions were required in 4% of patients. Inpatient aortic-related mortality was 2%, and all-cause inpatient mortality was 32%. Although survival at up to 4-7 years was reported, postdischarge follow-up after PSA NOM was limited to <1 year in most studies. CONCLUSIONS NOM of traumatic aortic PSAs is a common practice in BTAI series reporting lesion-specific management, and is associated with low rates of treatment failure. These findings suggest that routine early repair may not be required for traumatic PSAs, particularly for lesions limited to <50% of the aortic circumference. Definitive repair can be delayed until patient stability and repair timing can be guided by assessment of lesion stability on follow-up imaging.
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Affiliation(s)
- Donald G Harris
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Joseph Rabin
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Abhishek Bhardwaj
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Angelina S June
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Connor P Oates
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Danon Garrido
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ali Khoynezhad
- Division of Cardiothoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert S Crawford
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
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27
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Fortuna GR, Perlick A, DuBose JJ, Leake SS, Charlton-Ouw KM, Miller CC, Estrera AL, Azizzadeh A. Injury grade is a predictor of aortic-related death among patients with blunt thoracic aortic injury. J Vasc Surg 2016; 63:1225-31. [DOI: 10.1016/j.jvs.2015.11.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/12/2015] [Indexed: 11/27/2022]
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Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Nakanishi T, Ishida H. Blunt thoracic aortic injury with small pseudoaneurysm may be managed by nonoperative treatment. J Vasc Surg 2015; 63:341-4. [PMID: 26506935 DOI: 10.1016/j.jvs.2015.08.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The efficacy of nonoperative management of blunt thoracic aortic injury (BTAI) was evaluated in patients with pseudoaneurysm. METHODS A retrospective review was done for patients with BTAI at Fukui Prefectural Hospital during a 9-year period. Charts were reviewed for age, gender, Injury Severity Score, Abbreviated Injury Scale for each body area, initial type of aortic injury, site of aortic injury, type of definitive management, complications, and outcomes. RESULTS Eighteen patients with BTAI were treated at Fukui Prefectural Hospital. Of 18 patients with pseudoaneurysm, seven patients were hemodynamically unstable and four patients died because of associated injuries; there were no aortic-related deaths. All 14 surviving patients were followed up for an average of 40.9 months. Only two patients with pseudoaneurysm required operative management because of the progression of the pseudoaneurysm. The pseudoaneurysm/normal aortic diameter ratio of those with any intervention was higher than that of those with nonoperative management. CONCLUSIONS BTAI with pseudoaneurysm can be managed nonoperatively, with about 10% risk of progression to require surgical repair.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Aneurysm, False/diagnosis
- Aneurysm, False/mortality
- Aneurysm, False/physiopathology
- Aneurysm, False/therapy
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/physiopathology
- Aorta, Thoracic/surgery
- Aortography/methods
- Disease Progression
- Female
- Hemodynamics
- Humans
- Injury Severity Score
- Japan
- Male
- Middle Aged
- Retrospective Studies
- Thoracic Injuries/diagnosis
- Thoracic Injuries/mortality
- Thoracic Injuries/physiopathology
- Thoracic Injuries/therapy
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
- Vascular System Injuries/diagnosis
- Vascular System Injuries/mortality
- Vascular System Injuries/physiopathology
- Vascular System Injuries/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/physiopathology
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan.
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Makoto Sera
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideya Nagai
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Taizo Nakanishi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Ishida
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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Steuer J, Björck M, Sonesson B, Resch T, Dias N, Hultgren R, Tunesi R, Wanhainen A, Lachat M, Pfammatter T. Editor's Choice – Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers. Eur J Vasc Endovasc Surg 2015; 50:460-5. [DOI: 10.1016/j.ejvs.2015.05.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/10/2015] [Indexed: 11/26/2022]
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Harris DG, Rabin J, Kufera JA, Taylor BS, Sarkar R, O'Connor JV, Scalea TM, Crawford RS. A new aortic injury score predicts early rupture more accurately than clinical assessment. J Vasc Surg 2014; 61:332-8. [PMID: 25195146 DOI: 10.1016/j.jvs.2014.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/01/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
| | - Joseph Rabin
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Joseph A Kufera
- National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Bradley S Taylor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - Rajabrata Sarkar
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - James V O'Connor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Thomas M Scalea
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md; National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Robert S Crawford
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
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