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Giovannini E, Santelli S, Pelletti G, Bonasoni MP, Cornacchia A, Pelotti S, Fais P. Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation. Int J Legal Med 2024; 138:1329-1341. [PMID: 38337078 PMCID: PMC11164731 DOI: 10.1007/s00414-024-03174-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.
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Affiliation(s)
- Elena Giovannini
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
| | - Simone Santelli
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
| | - Guido Pelletti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
| | - Maria Paola Bonasoni
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy.
| | - Angela Cornacchia
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
| | - Paolo Fais
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, Bologna, 40126, Italy
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Florou M, Kepertis C, Stavridis K, Abatzis-Papadopoulos M, Tsopozidi M, Anastasiadis K, Tigkiropoulos K, Mouravas V. Endovascular Treatment With a Balloon-Expandable Covered Stent in a Polytrauma 12-Year-Old Patient With Traumatic Abdominal Aortic Rupture. Cureus 2024; 16:e63135. [PMID: 39055463 PMCID: PMC11271972 DOI: 10.7759/cureus.63135] [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] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Βlunt trauma is a common injury in children; however, blunt abdominal aortic trauma is extremely rare and is accompanied by high rates of morbidity and mortality. We report our initial experience with the endovascular management of an abdominal aortic rupture in a 12-year-old boy after he was involved in a motor vehicle accident. The patient was a backseat-restrained passenger. Upon admission, he had a Glasgow Coma Scale of 15, was hemodynamically stable, and complained of abdominal pain. The computed tomography revealed a rupture in the abdominal aorta along with a distally extending pseudoaneurysm, free fluid in the peritoneal cavity, and a large retroperitoneal hematoma. The rest associated injuries were a Grade III splenic injury, a retroclival epidural hematoma in the first cervical vertebra level, a right clavicle fracture, a bilateral minor pneumothorax, along with bilateral pulmonary lacerations and contusions in the thoracic vertebrae. Given the extent of the intraabdominal injuries and the risk for open laparotomy, the decision to proceed with endovascular stenting instead of open surgical repair was made. The patient tolerated the procedure well and an angiography confirmed the result. The postoperative period was uneventful and the associated injuries were treated conservatively without complications. Although blunt abdominal aortic trauma is extremely rare in children, endovascular management seems to be a new and feasible therapeutic approach.
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Affiliation(s)
- Maria Florou
- 2nd Department of Pediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
| | - Chrysostomos Kepertis
- 2nd Department of Pediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
| | - Kyriakos Stavridis
- Department of Vascular Surgery, Papageorgiou General Hospital, Thessaloniki, GRC
| | | | - Maria Tsopozidi
- 2nd Department of Pediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
| | - Kleanthis Anastasiadis
- Department of Pediatric Surgery, Papageorgiou General Hospital, Thessaloniki, GRC
- 2nd Department of Pediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
| | - Konstantinos Tigkiropoulos
- 1st Department of Surgery, Division of Vascular Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
- Department of Vascular Surgery, Papageorgiou General Hospital, Thessaloniki, GRC
| | - Vassileios Mouravas
- 2nd Department of Pediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, GRC
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Warner D, Holmes KW, Afifi R, Russo ML, Shalhub S. Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations. Semin Vasc Surg 2023; 36:340-354. [PMID: 37330246 DOI: 10.1053/j.semvascsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.
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Affiliation(s)
- David Warner
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code OP11, Portland, OR 97239
| | - Kathryn W Holmes
- Division of Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Melissa L Russo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code OP11, Portland, OR 97239.
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Jammeh ML, Ohman JW, Reed NR, English SJ, Jim J, Geraghty PJ. Management of Seat Belt-type Blunt Abdominal Aortic Trauma and Associated Injuries in Pediatric Patients. Ann Vasc Surg 2020; 69:447.e9-447.e16. [PMID: 32768538 DOI: 10.1016/j.avsg.2020.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND "Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries. METHODS -approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded. RESULTS We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation. CONCLUSIONS Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.
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Affiliation(s)
- Momodou L Jammeh
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - J Westley Ohman
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Nanette R Reed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Sean J English
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Jeffrey Jim
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Patrick J Geraghty
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
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Zhou YX, Ji Y, Chen J, Yang X, Zhou Q, Lv J. Common iliac artery occlusion with small intestinal transection caused by blunt abdominal trauma: A case report and review of the literature. World J Clin Cases 2019; 7:2120-2127. [PMID: 31423446 PMCID: PMC6695536 DOI: 10.12998/wjcc.v7.i15.2120] [Citation(s) in RCA: 3] [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: 02/26/2019] [Revised: 06/22/2019] [Accepted: 07/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most major abdominal vascular injuries are caused by penetrating injuries. A common iliac artery occlusion caused by blunt force trauma is rare, and very few cases have been reported. Because of this low incidence, atypical symptoms, and frequent association with other severe injuries, the proper diagnosis tends to be missed or delayed. The gold standard for diagnosis is angiography, and treatment remains a challenge. CASE SUMMARY We report here the unusual case of a common iliac artery occlusion caused by blunt abdominal compressive trauma, with transection of the small intestine. At presentation, the patient (a 56-year-old man) complained of pain and numbness in the left lower extremity and severe pain in the whole abdomen. Physical examination showed total abdominal tenderness with evidence of peritoneal irritation. The left lower limb was pulseless and cold. Abdominal computed tomography examination revealed digestive tract perforation, and abdominal computed tomography angiography showed left common iliac artery occlusion. The patient was treated successfully by anastomosis of the intestine, percutaneous transluminal angioplasty, and stenting. The patient was followed for more than 11 mo after the operation and showed a good recovery. CONCLUSION Patients with abdominal trauma should be suspected of having major vascular injury. Individualized treatment strategies are needed for this condition.
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Affiliation(s)
- You-Xin Zhou
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Yong Ji
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Jing Chen
- Imaging Department, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Xin Yang
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Qing Zhou
- Department of General Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - Jian Lv
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
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Glaser JD, Kalapatapu VR. Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature. Vasc Endovascular Surg 2019; 53:477-487. [DOI: 10.1177/1538574419844073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: To review the current use of endovascular techniques in trauma. Summary Background Data: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. Methods: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. Results: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. Conclusions: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.
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Affiliation(s)
- Julia D. Glaser
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Venkat R. Kalapatapu
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
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Karaolanis G, Moris D, McCoy CC, Tsilimigras DI, Georgopoulos S, Bakoyiannis C. Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma. Front Surg 2018; 5:7. [PMID: 29516005 PMCID: PMC5826055 DOI: 10.3389/fsurg.2018.00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 01/29/2018] [Indexed: 12/17/2022] Open
Abstract
The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.
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Affiliation(s)
- Georgios Karaolanis
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Hospital, Durham, NC, United States
| | - C. Cameron McCoy
- Department of Surgery, Duke University Hospital, Durham, NC, United States
| | - Diamantis I. Tsilimigras
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Georgopoulos
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Chris Bakoyiannis
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
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Increasing use of endovascular therapy in pediatric arterial trauma. J Vasc Surg 2017; 66:1175-1183.e1. [DOI: 10.1016/j.jvs.2017.04.072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/17/2017] [Indexed: 12/15/2022]
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Apodaka Diez A, Mikelarena Monteiro E, Gallardo Hoyos Y, Fonseca Legrand JL. Management and Evolution of a Wallstent Migration in a Pediatric Blunt Traumatic Abdominal Aortic Injury. Ann Vasc Surg 2017; 47:281.e15-281.e19. [PMID: 28947217 DOI: 10.1016/j.avsg.2017.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 08/04/2017] [Accepted: 09/07/2017] [Indexed: 11/18/2022]
Abstract
Blunt traumatic abdominal aortic injury in children is a rare but a severe condition. The clinical manifestation often involves other intra-abdominal visceral injuries and vertebral fractures. The best therapeutic management is still unclear with few reported endovascular cases treated. The following is the case of a 13-year-old male with an aortic abdominal dissection, spleen laceration, jejunal contusion, and hemoperitoneum after a motor vehicle collision. An endovascular approach was decided upon after the progression of the intimal aortic tear. A self-expanding stent was implanted into the injured position with an immediate proximal migration to the visceral aorta. It was decided not to retrieve the stent because of added comorbidity, and an open repair of the dissection was performed using a graft bypass. The patient has completed a 6-year image surveillance without complications or growth alterations. To our knowledge, this is the first reported childhood case of an intraoperative stent migration during the endovascular treatment of a blunt traumatic abdominal aortic injury. The possible cause of the complication and the management of these kinds of injuries are reviewed in detail in this article.
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Affiliation(s)
- Ana Apodaka Diez
- Department of Vascular Surgery, Hospital de Cruces, Barakaldo, Spain.
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Petrov I, Kaneva-Nencheva A, Levunlieva E, Genova K, Garvanski I, Konstantinov G, Adam G. Successful endovascular treatment of type B aortic dissection in a 15-year-old child. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chandhok P, Civil ID. Intraabdominal Vascular Injuries in Blunt Trauma: Spectrum of Presentation, Severity and Management Options. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0078-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last few years. RECENT FINDINGS Improved resource utilization in the diagnosis of pediatric abdominal injury has been described. Hemodynamic status, rather than grade of injury, now guides care. Stable patients spend less time in the hospital, return to school upon discharge, and are allowed lower hemoglobin levels prior to transfusion. ICUs are reserved for those with recent or ongoing bleeding, previously unstable patients, or children with concomitant injuries necessitating ICU. Risk factors for failure and evidence for adjuncts to nonoperative management are emerging. Operative management of certain pancreatic injuries may have more favorable outcomes than nonoperative management. SUMMARY Sufficient evidence has become available to radically change the management of pediatric abdominal injury, which is being incorporated into new evidence-based management algorithms.
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Deeney S, Bruny JL. Endovascular repair of traumatic aortic injury in a 16 month old. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mechanism and mortality of pediatric aortic injuries. J Surg Res 2015; 198:456-61. [DOI: 10.1016/j.jss.2015.03.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/09/2015] [Accepted: 03/19/2015] [Indexed: 01/26/2023]
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Yellinek S, Gimelrich D, Merin O, Reissman P, Arkovitz M. Aortic bifurcation tear following blunt trauma in childhood. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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