1
|
De Freitas S, Joyce D, Yang Y, Dunphy K, Walsh S, Fatima J. Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury. Ann Vasc Surg 2024; 98:220-227. [PMID: 37806657 DOI: 10.1016/j.avsg.2023.07.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/16/2023] [Accepted: 07/21/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. METHODS A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. RESULTS Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). CONCLUSIONS Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.
Collapse
Affiliation(s)
- Simon De Freitas
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC.
| | - Doireann Joyce
- Department of Vascular Surgery, Galway University Hospital, Galway, Republic of Ireland
| | - Yang Yang
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| | - Kaitlyn Dunphy
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| | - Stewart Walsh
- Department of Vascular Surgery, Galway University Hospital, Galway, Republic of Ireland
| | - Javairiah Fatima
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC
| |
Collapse
|
2
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
3
|
Olson KA, Chung CY, Aksamit NO, Hill CE, Brown CVR, Teixeira PG. Rule of four: an anatomic and value-based approach to stent-graft inventory for blunt thoracic aortic injury. Eur J Trauma Emerg Surg 2023; 49:2173-2176. [PMID: 37029792 DOI: 10.1007/s00068-023-02267-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/26/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory. METHODS CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr 2010-Dec 2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients. RESULTS Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2 years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series. CONCLUSIONS Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance.
Collapse
Affiliation(s)
- Kristofor A Olson
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA.
| | - C Yvonne Chung
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Nikolas O Aksamit
- Department of Mathematics and Statistics, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Charles E Hill
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA
| | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA.
| |
Collapse
|
4
|
Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | | |
Collapse
|
5
|
Slocum C, Chiba H, Emigh B, Tam B, Schellenberg M, Inaba K, Matsushima K. Nationwide Analysis of Penetrating Thoracic Aortic Injury: Injury Patterns, Management, and Outcomes. J Surg Res 2023; 284:290-295. [PMID: 36621259 DOI: 10.1016/j.jss.2022.11.077] [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: 08/18/2022] [Revised: 10/14/2022] [Accepted: 11/28/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Penetrating thoracic aortic injuries (PTAI) represent a rare form of thoracic trauma. Unlike blunt thoracic aortic injuries (BTAI), only scarce data, included in small case series, are currently available for PTAI. The purpose of this study was to describe injury patterns, surgical management, and outcomes of patients with PTAI and compare to those with BTAI. MATERIALS AND METHODS A 9-y retrospective cohort study (2007-2015) was conducted using the National Trauma Data Bank. Patient demographics, injury profile, procedures performed, and patient outcomes were compared between the PTAI and BTAI group. RESULTS A total of 2714 patients with PTAI and 14,037 patients with BTAI were identified. Compared to BTAI, PTAI patients were younger (28 versus 42 y, P < 0.001), more often male (89.1% versus 71.7%, P < 0.001), and more likely to arrive without signs of life (27.6% versus 7.5%, P < 0.001). PTAI patients had less associated injuries, overall, compared to those with BTAI; however, were more likely to have injuries to the esophagus, diaphragm, and heart. Patients with PTAI were less likely to undergo endovascular (5.8% versus 30.5%, P < 0.001) or open surgical repair (3.0% versus 4.2%, P < 0.001) compared to BTAI. While the large majority of PTAI patients expired before their hospital arrival or in the emergency department, the in-hospital mortality rate among those who survivedemergency department stay was 43.1%. CONCLUSIONS Most patients with PTAI present to the hospital without any signs of life, and their overall mortality rate is extremely high. Only a small portion of PTAI patients who survived the initial resuscitation period underwent surgical interventions for thoracic aortic injuries. Further studies are still warranted to clarify the indications and types of surgical interventions for PTAI.
Collapse
Affiliation(s)
- Charles Slocum
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Hiroto Chiba
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Brent Emigh
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Benjamin Tam
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California.
| |
Collapse
|
6
|
Osofsky R, Hanif H, Massie P, Ramey S, Miskimins R, Clark R, Rana MA, Guliani S. Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center. Ann Vasc Surg 2023:S0890-5096(23)00101-2. [PMID: 36805425 DOI: 10.1016/j.avsg.2023.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/04/2023] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. METHODS A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. RESULTS A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04). CONCLUSIONS Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).
Collapse
Affiliation(s)
- Robin Osofsky
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Hamza Hanif
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Pierce Massie
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Shannen Ramey
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Richard Miskimins
- Division of Acute Care Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Ross Clark
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Muhammad Ali Rana
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sundeep Guliani
- Division of Acute Care Surgery, University of New Mexico School of Medicine, Albuquerque, NM; Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| |
Collapse
|
7
|
Sorber R, Tsai LL, Hicks CW, Black JH. Midterm outcomes of isolated thoracic aortic replacement in congenital versus degenerative aortopathy in a 15-year institutional cohort. J Vasc Surg 2023; 77:20-27. [PMID: 36055553 PMCID: PMC9884488 DOI: 10.1016/j.jvs.2022.05.033] [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: 11/04/2021] [Revised: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Open aortic replacement represents the only approved option to address thoracic aortopathy among patients with connective tissue disorders (CTD). The aim of our study was to investigate contemporary midterm outcomes of isolated thoracic aortic replacement in patients with CTD versus degenerative pathology in a large institutional cohort. METHODS All patients undergoing isolated open thoracic aortic replacement at a single academic center from 2005 to 2020 were included. Patients were classified as having CTD or not having CTD based on documented genetic mutations associated with congenital aortopathy. In-hospital and midterm outcomes, including mortality, paraplegia, development of new arterial pathology on surveillance imaging, and the need for future operations, were compared between groups using descriptive statistics and Kaplan-Meier survival analysis. RESULTS Overall, 62 patients were included with a median follow-up of 58 months (range, 19-81 months) (59 months for those with CTD vs 51.5 months for those without CTD). CTD was present in 18 patients (29%), with 16 having Marfan syndrome (77.8%). Patients with CTD were younger than patients without CTD (45.8 years vs 60.9 years) and had lower rates of smoking (5.6% vs 56.8%) and hypertension (97.7% vs 72.2%; all P < .01). Patients with CTD were more likely to have a dissection component at the time of repair compared with patients without CTD (100% vs 59.1%) and underwent repair at smaller aortic diameters (5.9 cm vs 6.6 cm; both P < .05). There were no differences in in-hospital outcomes between the two groups, including mortality (4.5% vs 5.6%) and paraplegia (2.3% vs 0%; both P > .05). At 5 years, patients with CTD were more likely to have developed aneurysmal changes distal to their thoracic repair (88.9% vs 47.7%) and extra-aortic arterial aneurysms (41.2% vs 2.3%; both P < .05). However, on survival analysis, there were no differences in freedom from additional vascular procedures (hazard ratio,1.76; P = .333) or, specifically, additional aortic procedures (hazard ratio, 1.81; P = .380) between the two groups. There was only one anastomotic complication identified on longitudinal follow-up, which occurred in a patient without CTD 8 years after the index operation. CONCLUSIONS Although carrying significant operative risks and the potential for morbidity, open thoracic aortic replacement represents a well-tolerated, durable treatment option for patients with congenitally mediated thoracic aortic disease. Because both patients with and without CTD who required thoracic aortic replacement often need future aortic intervention, vigilant surveillance is warranted. Equivalent intervention rates between the two groups suggest remodeling of the CTD aorta is almost universally characterized by initial postrepair dilation, but the majority of these changes successfully stabilize and do not progress to higher rates of intervention.
Collapse
Affiliation(s)
- Rebecca Sorber
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD.
| | - Lillian L Tsai
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin W Hicks
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, MD
| | - James H Black
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| |
Collapse
|
8
|
Yau PO, Lewis E, Shah A, Stone ME, McNelis J, Rivera A. Blunt traumatic aortic injury in the elderly population. J Vasc Surg 2023; 77:47-55.e1. [PMID: 35948245 DOI: 10.1016/j.jvs.2022.07.180] [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: 04/13/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.
Collapse
Affiliation(s)
- Patricia O Yau
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY.
| | - Erin Lewis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Amit Shah
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Melvin E Stone
- Department of Surgery, Kings County Hospital, State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - John McNelis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Aksim Rivera
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| |
Collapse
|
9
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 446] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
10
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
11
|
Grigorian A, Lewis M, Wlodarczyk JR, Chien CY, Park T, Demetriades D. Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients. Eur J Trauma Emerg Surg 2022; 48:4425-4429. [PMID: 35713681 DOI: 10.1007/s00068-022-02027-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
Collapse
Affiliation(s)
- Areg Grigorian
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA.
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Jordan R Wlodarczyk
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Chih Ying Chien
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Timothy Park
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA
| |
Collapse
|
12
|
Ishimine T, Ishigami T, Chida K, Taniguchi N, Tengan T, Mototake H. Aortic injury repair in a patient with situs inversus totalis and dextrocardia. J Surg Case Rep 2022; 2022:rjac173. [PMID: 35441001 PMCID: PMC9013248 DOI: 10.1093/jscr/rjac173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/28/2022] [Indexed: 11/14/2022] Open
Abstract
Situs inversus totalis (SIT) with dextrocardia is a rare autosomal recessive disorder. We herein describe a blunt thoracic aortic injury (BTAI) in a patient with SIT and dextrocardia. An 18-year-old girl who was injured by a fall presented to our hospital. Computed tomography (CT) revealed a traumatic pseudoaneurysm at the aortic isthmus. Open aortic repair was performed through a right thoracotomy. No abnormal findings were observed on CT 1 year after the surgery. Open aortic repair of BTAI can be safely performed through a right thoracotomy in patients with SIT and dextrocardia.
Collapse
Affiliation(s)
- Tohru Ishimine
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Takahiro Ishigami
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Kohei Chida
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Naoki Taniguchi
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Toshiho Tengan
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Hidemitsu Mototake
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| |
Collapse
|
13
|
Evans LL, Aarabi S, Durand R, Upperman JS, Jensen AR. Torso vascular trauma. Semin Pediatr Surg 2021; 30:151126. [PMID: 34930597 DOI: 10.1016/j.sempedsurg.2021.151126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vascular injury within the chest or abdomen represents a unique challenge to the pediatric general surgeon, as these life- or limb-threatening injuries are rare and may require emergent treatment. Vascular injury may present as life-threatening hemorrhage, or with critical ischemia from intimal injury, dissection, or thrombosis. Maintaining the skillset and requisite knowledge to address these injuries is of utmost importance for pediatric surgeons that care for injured children, particularly for surgeons practicing in freestanding children's hospitals that frequently do not have adult vascular surgery coverage. The purpose of this review is to provide an overview of torso vascular trauma, with a specific emphasis in rapid recognition of torso vascular injury as well as both open and endovascular management options. Specific injuries addressed include blunt and penetrating mediastinal vascular injury, subclavian injury, abdominal aortic and visceral segment injury, inferior vena cava injury, and pelvic vascular injury. Operative exposure, vascular repair techniques, and damage control options including preperitoneal packing for pelvic hemorrhage are discussed. The role and limitations of endovascular treatment of each of these injuries is discussed, including endovascular stent graft placement, angioembolization for pelvic hemorrhage, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in children.
Collapse
Affiliation(s)
- Lauren L Evans
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Shahram Aarabi
- UCSF-East Bay Surgery Program, Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Rachelle Durand
- UCSF Benioff Children's Hospitals, and Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Aaron R Jensen
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| |
Collapse
|
14
|
Novak Z, Zaky A, Spangler EL, McFarland GE, Tolwani A, Beck AW. Incidence and predictors of early and delayed renal function decline after aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1537-1547. [PMID: 34019992 DOI: 10.1016/j.jvs.2021.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) may complicate both open and endovascular aortic aneurysm repair (EVAR) and is associated with substantial morbidity, mortality, and health care expense. We aim to evaluate the incidence of postoperative AKI and factors associated with its occurrence and the effects of postoperative AKI on long-term renal function and mortality after open and EVAR in the Society for Vascular Surgery Vascular Quality Initiative registry. METHODS Elective aneurysm cases were identified including thoracic endovascular aortic aneurysm repair (TEVAR) and complex endovascular aortic aneurysm repair (cEVAR), infrarenal endovascular repair (EVAR) and infrarenal open repair (OAR) from 2003 to 2019. The preoperative estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula and stratified based on chronic kidney disease (CKD) grades. Postoperative AKI was defined per the Vascular Quality Initiative definition as a creatinine increase of 0.5 mg/dL or if postoperative dialysis was required. Patients on preprocedural hemodialysis and those with previous renal transplant were excluded. Demographics and procedural factors were evaluated for predicting in-hospital postoperative AKI (all approaches) and at 9 to 21 months of long-term follow-up (EVAR only) using logistic regression modeling. RESULTS We identified a total of 2813 cEVAR, 2995 TEVAR, 39,945 EVAR, and 8143 OAR patients. Of those, postoperative AKI occurred in 377 cEVAR (13.5%), 199 TEVAR (6.7%), 1099 EVAR (2.8%), and 1249 OAR (15.5%). Risk factors for postoperative AKI across all groups were worse preoperative eGFR, total number of blood transfusions, perioperative anemia, reinterventions, and postoperative respiratory complications. Additional procedure-specific risk factors of postoperative AKI were preoperative hemoglobin of less than 10 and contrast volume of 125 to 150 mL, hypertension, a low ejection fraction, and a history of percutaneous revascularization for EVAR; for both EVAR/cEVAR, renal artery coverage was a risk factor, whereas for OAR, male sex, non-White race, hypertension, suprarenal aortic cross-clamp, and increased renal ischemic time were risk factors. Among 8133 EVAR patients with long-term follow-up, a decrease in kidney function occurred in 56.7% of patients with postoperative AKI vs 19.9% without postoperative AKI (P < .001). The following risk factors were associated with a decrease in renal function at long-term follow-up: postoperative AKI, a preoperative eGFR of less than 90, and hypertension. A preoperative hemoglobin of greater than 12 was protective. Postoperative AKI was associated with significantly lower survival compared with no postoperative AKI across all procedures (log rank <0.001). CONCLUSIONS Postoperative AKI occurs more often in patients with worse preoperative renal function, lower preoperative hemoglobin, and in open surgeries with inter-renal or suprarenal cross-clamping. Importantly, postoperative AKI is associated with increased mortality across all types of aortic repair. Given the long-term impact of postoperative AKI on outcomes for all aortic repairs and the limitations of current insensitive functional indices, there is a need to seek more sensitive indicators of decreases in early renal structural in this population.
Collapse
Affiliation(s)
- Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala.
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| |
Collapse
|
15
|
Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury: A case report. Chin J Traumatol 2021; 24:140-143. [PMID: 33678538 PMCID: PMC8173584 DOI: 10.1016/j.cjtee.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/24/2020] [Accepted: 01/20/2021] [Indexed: 02/04/2023] Open
Abstract
Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate of associated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 year-old-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.
Collapse
|
16
|
Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury. Ann Vasc Surg 2020; 73:22-26. [PMID: 33388410 DOI: 10.1016/j.avsg.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20 mm proximal seal zone is recommended based on aneurysmal disease literature which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20 mm is required to achieve successful remodeling. METHODS This is a single-center, retrospective study of all consecutive patients who received a TEVAR for treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) scan centerline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications. RESULTS Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with an average distance from the LSA to the injury of 6.4 mm (0-15.1 mm). Of the 33 (54%) patients who did not undergo coverage of the LSA, 22 patients (66%) had less than 20 mm of proximal seal zone. The mean distance from the LSA to injury in this group was 16.6 mm (7.9-29.5 mm). None of the patients with LSA coverage developed ischemic symptoms, and an average decrease in left arm systolic blood pressure of 24.8 mm Hg (0-62 mm Hg) was noted versus the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling. CONCLUSIONS Immediate outcomes of TEVAR for TBAI with LSA coverage are well tolerated; however, the long-term sequela of LSA coverage is unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20 mm of proximal seal, and perhaps more attention should be made to preservation of the LSA.
Collapse
|
17
|
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.
Collapse
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
| | | | | | | |
Collapse
|
18
|
Lee JH, Cho Y, Cho YH, Kang H, Lim TH, Jang HJ, Ro SK, Kim H. Incidence and Mortality Rates of Thoracic Aortic Dissection in Korea - Inferred from the Nationwide Health Insurance Claims. J Korean Med Sci 2020; 35:e360. [PMID: 33075856 PMCID: PMC7572231 DOI: 10.3346/jkms.2020.35.e360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/14/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Aortic dissection (AD) is one of the most catastrophic diseases and is associated with high morbidity and mortality. The aim of this study is to investigate the hospital incidence and mortality rates of thoracic AD in Korea using a nationwide database. METHODS We conducted a nationwide population-based study using the health claims data of the National Health Insurance Service in Korea. From 2005 to 2016, adult patients newly diagnosed with AD were included. All patients were divided into the following four subgroups by treatment: type A surgical repair (TASR), type B surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). The incidence rate, mortality rate, and risk factors of in-hospital mortality were evaluated. RESULTS In total, 18,565 patients were newly diagnosed with AD (TASR, n = 4,319 [23.3%]; TBSR, n = 186 [1.0%]; TEVAR, n = 697 [3.8%]; MM, n = 13,363 [72.0%]). The overall AD incidence rate was 3.76 per 100,000 person-years and exhibited a gradual increase during the study period (3.29 to 4.82, P < 0.001). The overall in-hospital mortality rate was 10.84% and remained consistent (P = 0.57). However, the in-hospital mortality rate decreased in the TASR subgroup (18.23 to 11.27%, P = 0.046). An older age, the female sex, hypertension, and chronic kidney disease were independent risk factors for in-hospital mortality. CONCLUSION The incidence of thoracic AD has gradually increased in Korea. The in-hospital mortality in the TASR subgroup decreased over the decade, although the overall mortality of AD patients did not change.
Collapse
Affiliation(s)
- Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Yongil Cho
- Department of Emergency Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Hyo Jun Jang
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Sun Kyun Ro
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Hyuck Kim
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea.
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Nana PN, Brotis AG, Tsolaki V, Spanos K, Mpatzalexis K, Zakynthinos E, Giannoukas AD, Kouvelos GN. Transesophageal echocardiography during endovascular procedures for thoracic aorta diseases: sensitivity and specificity analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:79-86. [PMID: 32909705 DOI: 10.23736/s0021-9509.20.11427-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The widespread use of endovascular repair in thoracic aorta (TEVAR) pathologies has ameliorated postoperative outcomes. This meta-analysis was designed to investigate the intra-operative use of transesophageal echocardiography (TEE) compared to angiography in patients undergoing TEVAR. EVIDENCE ACQUISITION The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until November 30, 2019. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the summary of findings for each of the included outcomes. EVIDENCE SYNTHESIS The final analysis included 7 articles (183 patients). All patients underwent TEVAR using intra-operative TEE and angiography. The sensitivity and specificity rates of entry points were 0.624 (95% CI: 0.145-0.97) and 0.377 (95% CI: 0.029-0.856), respectively. Regarding the detection of adequate guidewire advancement, the sensitivity was 0.778 (95% CI: 0.288-939) and specifity 0.346 (95% CI: 0.019-0.844). TEE could detect endograft incomplete deployment within acceptable rates of sensitivity and specifity, estimated at 0.616 (95% CI: 0.141-0.971) and 0.365 (95% CI: 0.028-0.845), respectively. The intra-operative detection of endoleaks presented a sensitivity estimated at 0.875 (0.51-0.998) and specificity at 0.698 (95% CI: 0.284-0.904). CONCLUSIONS Despite the limitations of this analysis, TEE may be evaluated in the current endovascular era, as a useful tool, providing adequate information, on graft deployment and early endoleaks.
Collapse
Affiliation(s)
- Petroula N Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece -
| | - Alexandros G Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Vassiliki Tsolaki
- Intensive Care Unit, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Konstantinos Mpatzalexis
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Epaminondas Zakynthinos
- Intensive Care Unit, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, Larissa University Hospital, University of Thessaly, Larissa, Greece
| |
Collapse
|
21
|
Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center. Ann Thorac Surg 2020; 110:524-530. [DOI: 10.1016/j.athoracsur.2019.11.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/13/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
|
22
|
Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2020; 110:1469-1474. [PMID: 32535042 DOI: 10.1016/j.athoracsur.2020.04.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/04/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. METHODS Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. RESULTS During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. CONCLUSIONS A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
Collapse
|
23
|
Abstract
More than 45% of polytraumatized patients in Germany suffer from severe thoracic trauma. Due to the urgent time factor (e.g. respiratory insufficiency and severe bleeding), a structured procedure in the diagnostics and treatment according to the advanced trauma life support (ATLS) criteria is necessary both prehospital and in the emergency room in order to provide the patient with adequate care. If a patient is stable or can be stabilized there is the option of using extended diagnostics, such as whole body computer tomography (CT) scanning with contrast medium, to select a treatment that is optimally adapted to the injury pattern. This can be performed by open surgery, minimally invasive surgery and interventional radiologically/endoscopically and depends on the injured organ as well as the extent of the injury. This means that only an interdisciplinary approach guarantees optimal care for patients with thoracic trauma.
Collapse
|
24
|
Elongation of the Aorta after Thoracic Endovascular Aortic Repair: A longitudinal study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041205. [PMID: 32069982 PMCID: PMC7068526 DOI: 10.3390/ijerph17041205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 01/28/2023]
Abstract
Aortic morphology is associated with age, with the diameter being larger in older people. Thoracic endovascular aortic repair (TEVAR) is a treatment for aortic diseases, such as aortic dissection. When evaluating patients, aortic elongation could interfere with the classification of TEVAR complications. The longitudinal change in aortic length has not been studied in detail. In patients receiving thoracic endovascular aortic repair between 2007 and 2013, we determined the aortic length between the sinotubular junction, left common carotid artery, subclavian artery, and celiac artery on their first five annual follow-up computed tomography (CT) exams. Using the immediate post-TEVAR follow-up CT as the comparison reference and a lengthening of the aortic segment by 10 mm or more as the definition of elongation, 16 of 41 (39%) showed elongation between the innominate artery and celiac artery. When compared with the immediate follow-up CT, a higher proportion of patients showed elongation at the fifth year’s follow-up CT than the first year’s follow-up CT (p < 0.01), and the average lengthening per year was 1.7 mm. There was progressive lengthening of the aorta after TEVAR.
Collapse
|
25
|
Elkbuli A, Dowd B, Spano PJ, Smith Z, Flores R, McKenney M, Boneva D. Thoracic Endovascular Aortic Repair Versus Open Repair: Analysis of the National Trauma Data Bank. J Surg Res 2020; 245:179-182. [DOI: 10.1016/j.jss.2019.07.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/17/2019] [Accepted: 07/19/2019] [Indexed: 11/29/2022]
|
26
|
Ruan WS, Lu YQ. The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury. World J Emerg Med 2020; 11:152-156. [PMID: 32351647 DOI: 10.5847/wjem.j.1920-8642.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Fatal aortic rupture caused by esophageal foreign body (EFB), is associated with a high mortality, but can be prevented by thoracic endovascular aorta repair (TEVAR) that performed increasingly as technology improves. This study aims to investigate the cause, management and prognosis of suspected penetrating aortoesophageal foreign body injury. METHODS Twelve cases who met the criteria were enrolled in this study. The demographic and clinical data were reviewed for evaluating the characteristics of EFB. RESULTS Among 12 cases enrolled, 7 were males and 5 were females, with an age 27-86 years. The distance of EFB from aorta (DFA) of 7 cases were less than or equal to 0 mm, 5 cases were 0-2 mm. Eleven cases were managed with TEVAR, only one case was with open surgery standby but finally treated by flexible endoscopy (FE) successfully, without TEVAR. In group with TEVAR, EFB of 7 cases were successfully removed by rigid endoscopy (RE), and one of them was failed at the first RE treatment. EFB of 2 cases were successfully removed by open surgery with TEVAR, and other 9 cases were managed by endoscopies with TEVAR. The mean length of stay of hospitalization (LOS) and length of ICU stay of patients treated by open surgery with TEVAR (18.50±2.12 days and 5.50±0.71 days) was significantly longer than those of patients treated by endoscopy with TEVAR (7.00±2.74 days and 1.33±1.12 days, P<0.001 and P=0.001, respectively). Five cases had severe complications. CONCLUSION Rational application of TEVAR can be a life-saving management for aortoesophageal foreign body injury, and jointed with endoscopy is safe and effective with a shorter length of ICU or total hospital stay.
Collapse
Affiliation(s)
- Wei-Shuyi Ruan
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,Department of Geriatric Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yuan-Qiang Lu
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,Department of Geriatric Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| |
Collapse
|
27
|
Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients. J Interv Med 2019; 2:150-153. [PMID: 34805892 PMCID: PMC8562287 DOI: 10.1016/j.jimed.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Methods Results Conclusion
Collapse
|
28
|
Zhang HW, Huang Y, Yang P, Li KD, Hu J. Urgent retrograde two-stage hybrid repair of a complicated blunt traumatic aortic injury. J Vasc Surg 2019; 70:1669-1672. [PMID: 31521399 DOI: 10.1016/j.jvs.2018.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/26/2018] [Indexed: 02/05/2023]
Abstract
Blunt traumatic aortic injury (BTAI) is a rare but life-threatening emergency that is usually caused by sudden acceleration/deceleration injuries in vehicular accidents. We describe our initial experience of a retrograde two-stage hybrid treatment approach for the emergent management of a 63-year-old motorcyclist who presented with a complicated BTAI with malperfusion syndrome. To our best knowledge, this uncommon BTAI case with fatal distal malperfusion saved by an urgent retrograde two-stage hybrid procedure has been reported rarely. This early reperfusion strategy with two-stage retrograde endovascular technique could be an effective and life-saving treatment option for polytrauma patients with suitable aortic anatomy.
Collapse
Affiliation(s)
- Hong-Wei Zhang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yao Huang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Peng Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Kai-di Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
| |
Collapse
|
29
|
Hasjim BJ, Grigorian A, Barrios C, Schubl S, Nahmias J, Gabriel V, Spencer D, Donayre C. National Trends of Thoracic Endovascular Aortic Repair versus Open Thoracic Aortic Repair in Pediatric Blunt Thoracic Aortic Injury. Ann Vasc Surg 2019; 59:150-157. [PMID: 30802562 DOI: 10.1016/j.avsg.2018.12.094] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/22/2018] [Accepted: 12/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI, but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared with open thoracic aortic repair (OTAR). METHODS The National Trauma Data Bank (2007-2015) was queried for patients ≤17 years with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine the risk of mortality in OTAR versus TEVAR. RESULTS We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, P < 0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (P > 0.05). Compared with OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, P = 0.005) and shorter hospital and intensive care unit length of stay (LOS) (16.4 vs. 21.4 days, P = 0.02; 10.1 vs. 12.2 days, P = 0.01). TEVAR and OTAR, even when stratified by ≤14 years and 15-17 years, had no difference in risk for mortality (odds ratio 1.20, confidence interval 0.29-5.01, P = 0.80). CONCLUSIONS The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared with OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including reintervention, development of endoleak, and/or need for further operations, are needed as this technology is being rapidly adopted for pediatric trauma patients.
Collapse
Affiliation(s)
- Bima J Hasjim
- Department of Surgery, University of California, Irvine, Orange, CA, USA.
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Sebastian Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Viktor Gabriel
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Dean Spencer
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Carlos Donayre
- Division of Vascular Surgery, Department of Surgery, University of California, Orange, Irvine, CA, USA
| |
Collapse
|
30
|
Scalea TM, Feliciano DV, DuBose JJ, Ottochian M, O'Connor JV, Morrison JJ. Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard. J Am Coll Surg 2019; 228:605-610. [PMID: 30630086 DOI: 10.1016/j.jamcollsurg.2018.12.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI. STUDY DESIGN The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes. RESULTS There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p < 0.001), median ISS decreased from 38 to 33 (p < 0.001), and significantly more patients were treated at a level I trauma center (p < 0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p < 0.001) and in those treated operatively (0.0% to 94.9%, p < 0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR. CONCLUSIONS The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation.
Collapse
Affiliation(s)
- Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - James V O'Connor
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| |
Collapse
|
31
|
Lee CJ, Loo R, Wohlauer MV, Patel PJ. Diagnostic workup and endovascular treatment of popliteal artery trauma. VASA 2018; 48:65-71. [PMID: 30326793 DOI: 10.1024/0301-1526/a000756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.
Collapse
Affiliation(s)
- Cheong J Lee
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Rory Loo
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Max V Wohlauer
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Parag J Patel
- 2 Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, USA
| |
Collapse
|