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Sarquis LM, Michaelis W, Santos AL, Pinto CS, Yokoyama RA, Seguro EF, Martins ALDC, do Vale VB. Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases. J Vasc Bras 2020; 19:e20200074. [PMID: 34211523 PMCID: PMC8218017 DOI: 10.1590/1677-5449.200074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown. Objectives The aim of this study is to describe a specialist trauma center’s experience with endovascular treatment of cases like these. Methods This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil). Results Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection). Conclusions The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.
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Affiliation(s)
| | - Wilson Michaelis
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | - Antonio Lacerda Santos
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
| | | | - Rogerio Akira Yokoyama
- Hospital Universitário Evangélico Mackenzie - HUEM, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil
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Endovascular repair of traumatic aortic isthmic rupture: Early and mid-term results. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:254-259. [PMID: 32862982 DOI: 10.1016/j.jdmv.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/13/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Conventional open repair of a traumatic aortic isthmic rupture is associated with a significantly high mortality and morbidity rates. Thoracic endovascular aortic repair (TEVAR) is currently often performed because it is a less invasive treatment than surgery. The aim of this study was to evaluate short and mid-term results of TEVAR in traumatic aortic isthmic rupture. METHODS This is a retrospective study conducted between 2010 and 2018 including patients who underwent TEVAR for traumatic aortic isthmic rupture. RESULTS Thirty-six consecutive patients were included. All patients had sustained a violent blunt chest trauma after a sudden deceleration with associated injuries. The injury severity score (ISS) was 40 (14-66). All patients were hemodynamically stable at admission. We deployed thoracic aorta stent grafts with a mean diameter of 26mm (18-36). The procedural success rate was 100%. We reported one intra-operative complication which was a distal migration of the graft, managed by an implantation of an aortic extension graft. On the first postoperative day, one patient presented an acute lower limb ischemia, probably due to the surgical femoral access, treated with an embolectomy with a Fogarty catheter with satisfactory results. The mean follow-up was 40.41 months (6.5-96). The mortality and paraplegia rates were 0% at one month and during the follow-up period. We reported a case of kinking of the graft that occurred at 6 months. No cases of endoleak neither re-intervention were reported. CONCLUSION TEVAR is a safe and a reliable method for the treatment of sub-acute traumatic thoracic aortic injuries.
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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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Ho XN, Wee IJ, Syn N, Harrison M, Wilson L, Choong AM. The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis. Vascular 2019; 27:213-223. [PMID: 30739602 DOI: 10.1177/1708538119828887] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. METHOD This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). RESULTS Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100 min (95%CI 63.5-136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. CONCLUSION Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.
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Affiliation(s)
- Xin Nee Ho
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore
| | - Ian Jy Wee
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore
| | - Michael Harrison
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,4 Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Australia
| | - Lauren Wilson
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,5 School of Medicine, Griffith University, Gold Coast, Australia
| | - Andrew Mtl Choong
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore.,6 Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,7 Department of Surgery, National University of Singapore, Singapore
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Kovari VZ, Pecsi F, Cs Janvari M, Veres R. Initial experience with the treatment of concomitant aortic pseudoaneurysm and thoracolumbar spinal fracture: Case report. Trauma Case Rep 2018; 12:48-53. [PMID: 29644285 PMCID: PMC5887094 DOI: 10.1016/j.tcr.2017.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/26/2022] Open
Abstract
One blunt abdominal aortic disruption (BAAD) and one blunt thoracic aortic injury (BTAI) case are presented. Both aortic injuries were combined with spinal fractures. In the BAAD case the aortic pseudoaneurysm manifested just above the lumbar fracture while in the BTAI case the aortic injury appeared several vertebras below the thoracal fracture site, suggesting different mechanisms in the aortic wall damage. In both cases the aortic wall first was sealed, successfully, by endovascularly-placed stents, meaning the risks of open aortic reconstructive surgery could be avoided. The adjacent crucial vessel's preservation, despite the stent covering the left subclavian artery and the left common carotid artery in one of the cases was verified by post-operative computed tomography angiography (CTA) examination. In second stage those spinal fractures which were deemed unstable were stabilized by the fixateur interne (a transpedicular screw-rod system). With this treatment sequence we wanted to avoid the unnecessary risk of a possible rupture of the unsealed aortic wall during positioning for the spinal procedure and during the spinal surgery. Both patients recovered from their aortic and spinal injuries.
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Affiliation(s)
- Viktor Zsolt Kovari
- Hungarian Defense Forces Medical Centre, Department of Neurosurgery, Robert Karoly krt. 44, 1134 Budapest, Hungary
| | - Ferenc Pecsi
- Spinal Surgery and Scolisos Centre, Schön Klinik Neustadt, Am Kiebitzberg 10, 23730 Neustadt in Holstein, Germany
| | - Mate Cs Janvari
- Hungarian Defense Forces Medical Centre, Department of Radiology, Robert Karoly krt. 44, 1134 Budapest, Hungary
| | - Robert Veres
- Mafraq Hospital, Department of Neurosurgery, P.O. Box. 2951, Abu Dhabi, United Arab Emirates
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Patelis N, Katsargyris A, Klonaris C. Endovascular Repair of Traumatic Isthmic Ruptures: Special Concerns. Front Surg 2017; 4:32. [PMID: 28660196 PMCID: PMC5466971 DOI: 10.3389/fsurg.2017.00032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 05/26/2017] [Indexed: 01/16/2023] Open
Abstract
Injury of the aortic isthmus is the second most frequent cause of death in cases of blunt traumatic injury. Conventional open repair is related to significant morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) has increasing role in traumatic isthmic rupture, as it avoids the thoracotomy-related morbidity, aortic cross clamping, and cardiopulmonary bypass. Additionally to the technical difficulties of open repair, multi-trauma patients may not tolerate the manipulations necessary to undergo open surgery, due to concomitant injuries. TEVAR is a procedure easier to perform compared to open surgery, despite that a considerable degree of expertise is necessary. Direct comparison of the two methods is difficult, but TEVAR appears to offer better results than open repair in terms of mortality, incidence of spinal cord ischemia, renal insufficiency, and graft infection. TEVAR is related to a-statistically not significant-trend for higher re-intervention rates during the follow-up period. Current guidelines support TEVAR as a first-line repair method for traumatic isthmic rupture. Certain specific considerations related to TEVAR, such as the timing of the procedure, the type and oversizing of the endograft, heparinization during the procedure, the necessity of cerebrospinal fluid drainage, type of anesthesia, and the necessary follow-up strategy remain to be clarified. TEVAR should be considered advantageous compared to open surgery, but future developments in endovascular materials, along with accumulating long-term clinical data, will eventually improve TEVAR results in traumatic aortic isthmic rupture (TAIR) cases. This publication reviews the role, outcomes, and relevant issues linked to TEVAR in the repair of TAIR.
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Affiliation(s)
- Nikolaos Patelis
- First Department of Surgery, Vascular Unit, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Chris Klonaris
- First Department of Surgery, Vascular Unit, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
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van der Zee CP, Vainas T, van Brussel FA, Tielliu IF, Zeebregts CJ, van der Laan MJ. Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2017; 60:100-110. [PMID: 28471152 DOI: 10.23736/s0021-9509.17.09942-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications. EVIDENCE ACQUISITION PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted. EVIDENCE SYNTHESIS A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon. CONCLUSIONS TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.
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Affiliation(s)
- Cornelis P van der Zee
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands -
| | - Tryfon Vainas
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Ignace F Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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