1
|
Starnes BW, Rajani RR, Rossi P, Singh N, Benarroch-Gampel J, Cho JS, Nassiri N, Smeds MR, Kalapatapu V, Stern JR, Kabutey NK, Corvera J. Early survival benefit of a low-profile endograft in blunt traumatic aortic injury. J Vasc Surg 2024; 80:678-684.e1. [PMID: 38677660 DOI: 10.1016/j.jvs.2024.04.051] [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: 01/16/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. METHODS A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. RESULTS The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. CONCLUSIONS RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.
Collapse
Affiliation(s)
| | - Ravi R Rajani
- Department of Surgery, Emory University School of Medicine and Grady Health System, Atlanta, GA
| | - Peter Rossi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Niten Singh
- Department of Surgery, Harborview Medical Center, Seattle, WA
| | | | - Jae S Cho
- Department of Surgery, University Hospitals Cleveland, Cleveland, OH
| | - Naiem Nassiri
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Venkat Kalapatapu
- Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | | | | | - Joel Corvera
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
2
|
Jubouri M, Surkhi AO, Al-Tawil M, Geragotellis A, Abdaljawwad TZI, Qudaih M, Elrayes MIR, Dewi M, Moothathamby T, Hammad A, Mohammed I, Awad WI, D'Oria M, Piffaretti G, Bailey DM, Williams IM, Bashir M. Long-Term Survival and Reintervention Following Thoracic Endovascular Aortic Repair in Blunt Traumatic Thoracic Aortic Injury: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 109:162-176. [PMID: 39004278 DOI: 10.1016/j.avsg.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI. MATERIAL AND METHODS A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4. RESULTS 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I2 = 70.6%). This was 91% (95% CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I2 = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I2 = 81.7%). CONCLUSIONS Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities.
Collapse
Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | | | | | - Mohanad Qudaih
- Faculty of Medicine, Al-Quds University, Jerusalem Palestine
| | - Mohammed I R Elrayes
- Department of Paediatric Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Madlen Dewi
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Thurkga Moothathamby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aya Hammad
- Hull York Medical School, University of York, York, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Piffaretti
- Vascular Surgery-Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
| |
Collapse
|
3
|
AlQurashi HE, Alzahrani HA, Bafaraj MO, Bosaeed M, Almasabi M, Banhidarah A. Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience. Cureus 2024; 16:e55327. [PMID: 38559515 PMCID: PMC10981867 DOI: 10.7759/cureus.55327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings. Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay. RESULTS A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05). CONCLUSION Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.
Collapse
Affiliation(s)
| | | | | | - Mohammed Bosaeed
- Vascular and Endovascular Surgery, Alnoor Specialist Hospital, Makkah, SAU
| | | | | |
Collapse
|
4
|
Nana P, Spanos K, Behrendt CA, Brodis A, Haulon S, Kölbel T. A Systematic Review on Thoracic Endovascular Repair Outcomes in Blunt Thoracic Aortic Injuries. J Endovasc Ther 2024:15266028241233163. [PMID: 38369733 DOI: 10.1177/15266028241233163] [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: 02/20/2024]
Abstract
PURPOSE Blunt thoracic aortic injury (BTAI) represents a potentially life-threatening condition and thoracic endovascular aortic repair (TEVAR) is recommended as the first-line treatment (Class I level of evidence C) by the current guidelines. The aim of this systematic review was to determine the perioperative and mid-term follow-up outcomes of patients with BTAI treated with TEVAR. MATERIALS AND METHODS We reviewed the English literature published between 2000 and 2022, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until July 30, 2022. Observational studies and case series, with ≥5 patients, reporting on the perioperative and follow-up outcomes of patients who underwent TEVAR for BTAI were included. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, cerebrovascular morbidity. Secondary outcomes were mortality and re-interventions during the mid-term follow-up. RESULTS From 5201 articles identified by the literature search, 35 eligible studies were included in this review. All studies had a retrospective study design. In total, 991 patients were included. The mean age was 34.5±16.5 years (range=16-89 years). Technical success was 98.0% (odds ratio [OR], 95% confidence interval [CI]=0.98, 0.99, p<0.001, I2=0%). Mortality at 30 days was 5.0% (OR, 95% CI=0.03, 0.06, p<0.001, I2=5.56%). Spinal cord ischemia occurred in 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and stroke rate was 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%). The available follow-up was estimated at 29 months (range=3-119 months) with mortality rate at 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and re-intervention rate at 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=10.5%). CONCLUSION Thoracic endovascular aortic repair showed high technical success and low early cerebrovascular morbidity and mortality rates. In the mid-term follow-up, the estimated mortality and re-intervention rates were also low. Furthermore, higher quality prospective studies are needed. CLINICAL IMPACT Thoracic endovascular aortic repair (TEVAR) is recommended as the first line treatement in patients with blunt thoracic aortic injuries (BTAI). This systematic review of 35 retrospective studies and 991 patients showed high technical success (98.0%) with an associated 30-day mortality at 5.0% and low spinal cord ischemia (1%) and stroke rates (2.0%). Mid-term mortality and re-intervention rates reassure the effectiveness of TEVAR in BTAI cases.
Collapse
Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Paris, France
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Christian-Alexander Behrendt
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Alexandros Brodis
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Paris, France
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| |
Collapse
|
5
|
Bayona JG, Rey Chaves CE, Hernández Rodríguez OG, Barón V, Fajardo E, Posada E. Case report: Endovascular stent-graft repair of aortic penetrating trauma, literature review, and case report. Front Surg 2023; 10:1264558. [PMID: 37886635 PMCID: PMC10598695 DOI: 10.3389/fsurg.2023.1264558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Penetrating aortic injuries are infrequent. Its incidence is unknown because most patients die of hemorrhage even before they receive adequate treatment. Aortic wounds generally require conventional thoracotomy/laparotomy repair and are related to high mortality rates. Recently with the advent of endovascular techniques, most authors prefer endovascular management when feasible due to better (still poor) outcomes. The short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are promising, especially when compared with open surgical treatment, indicating that endovascular therapy is preferable in patients with multi-trauma and traumatic ruptures of the thoracic aorta. Here we present the diagnosis and treatment of a 30 years-old male patient with multiple traumatic stab wounds, including anterior aortic laceration with a grade II aortic lesion successfully managed with an endovascular stent graft.
Collapse
Affiliation(s)
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia
| | - Oscar Geovanny Hernández Rodríguez
- Cirugía Vascular Periférica, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Vladimir Barón
- Cirugía Vascular Periférica, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Ernesto Fajardo
- Cirugía Vascular Periférica, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Eduardo Posada
- Estudiante de Posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia
| |
Collapse
|
6
|
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
|
7
|
Mavioglu L, Iscan HZ, Askin G, Akkaya BB, Tumer NN, Karahan M, Unal EU. Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results. J Endovasc Ther 2023:15266028231199036. [PMID: 37728012 DOI: 10.1177/15266028231199036] [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: 09/21/2023]
Abstract
AIM Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. MATERIALS AND METHODS Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. RESULTS The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. CONCLUSION TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. CLINICAL IMPACT Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.
Collapse
Affiliation(s)
- Levent Mavioglu
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Hakki Zafer Iscan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Goktan Askin
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | | | - Naim Noran Tumer
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Türkiye
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Ufuk University, Ankara, Türkiye
| |
Collapse
|
8
|
Evans CCD, Li W, Yacob M, Brogly S. Longer-term rates of survival and reintervention after thoracic endovascular aortic repair (TEVAR) for blunt aortic injury: a retrospective population-based cohort study from Ontario, Canada. Trauma Surg Acute Care Open 2022; 7:e000856. [PMID: 35402731 PMCID: PMC8948392 DOI: 10.1136/tsaco-2021-000856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/02/2022] [Indexed: 11/03/2022] Open
Abstract
Objectives Blunt aortic injury (BAI) is associated with a high rate of mortality. Thoracic endovascular aortic repair (TEVAR) has emerged as the preferred treatment option for patients with BAI. In this study, we compare the longer-term outcomes of patients receiving TEVAR with other treatment options for BAI. Methods We conducted a retrospective cohort study using administrative health data on patients with BAI in Ontario, Canada between 2009 and 2020. Patients with BAI and who survived at least 24 hours after hospital admission were identified using diagnostic codes. We classified patients as having received TEVAR, open surgical, hybrid repair, or medical management as their initial treatment approach based on procedure codes. The primary outcome was survival to maximum follow-up. Secondary outcomes included aorta-related mortality or aortic reintervention. Cox's proportional hazards models were used to estimate the effect of TEVAR on survival. Results 427 patients with BAI were followed for a median of 3 years (IQR: 1-6 years), with 348 patients (81.5%) surviving. Survival to maximum follow-up did not differ between treatment groups: TEVAR: 79%, surgical repair: 63.6%, hybrid repair: 85.7%, medical management: 83.3% (p=0.10). In adjusted analyses, TEVAR was not associated with improved survival compared with surgical repair (HR: 0.6, 95% CI: 0.3 to 1.6), hybrid repair (HR: 1.4, 95% CI: 0.5 to 3.6), or medical management (HR: 1.5, 95% CI: 0.8 to 2.6). Aortic reinterventions were required in only 2.6% of surviving patients but were significantly more common in the TEVAR group (p<0.01). Conclusions The longer-term survival from BAI appears highly favorable with low rates of reintervention and death in the years after injury, regardless of the initial treatment approach. Level of evidence IV, Therapeutic study.
Collapse
Affiliation(s)
- Christopher C D Evans
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada,Institute of Clinical and Evaluative Sciences, Queen's University, Kingston, Ontario, Canada
| | - Wenbin Li
- Institute of Clinical and Evaluative Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michael Yacob
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Susan Brogly
- Institute of Clinical and Evaluative Sciences, Queen's University, Kingston, Ontario, Canada,Department of Surgery, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
9
|
Al-Thani H, Hakim S, Asim M, Basharat K, El-Menyar A. Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital. Eur J Trauma Emerg Surg 2022; 48:4079-4091. [PMID: 35286404 PMCID: PMC9532277 DOI: 10.1007/s00068-022-01930-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center. METHODS We conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan-Meier curve and Cox regression analysis were performed for the outcome. RESULTS Eighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I-IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I-II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001). CONCLUSIONS BTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.
Collapse
Affiliation(s)
- Hassan Al-Thani
- Trauma and Vascular Surgery Section, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Suhail Hakim
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| |
Collapse
|
10
|
TEPE M, ARSLAN FD, KİLCİ Aİ, HAKKOYMAZ H, GEDİK MS. A RARE DİAGNOSİS AFTER A TRAFFİC ACCİDENT AORTİC TRANSECTİON. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2022. [DOI: 10.33706/jemcr.1058917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
11
|
Zhou Q, Ye M, Wei Y, Wu J, Shen Y, Zheng T, Shao G. The endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single-center experience. VASCULAR INVESTIGATION AND THERAPY 2022. [DOI: 10.4103/2589-9686.348222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
12
|
Benz RM, Makaloski V, Brönnimann M, Mertineit N, von Tengg-Kobligk H. [Diagnostics and treatment of traumatic aortic injuries]. Unfallchirurg 2021; 124:601-609. [PMID: 34254152 PMCID: PMC8370906 DOI: 10.1007/s00113-021-01044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund Traumatische Aortenverletzungen (TAV) sind seltene Folgen von stumpfen Traumata, die eine hohe Mortalität und Morbidität aufweisen. Die schnelle und akkurate Diagnostik sowie die Wahl der korrekten Therapie sind für das Patientenüberleben elementar. Fragestellung Bestimmung des aktuellen Standards der Abklärung von TAV im akuten Trauma-Setting und Evaluation der aktuellen Leitlinien zur Therapie. Material und Methode Eine Literaturrecherche wurde durchgeführt, mit der Suche nach Publikationen, die die Abklärung und Diagnostik der TAV beschreiben. Außerdem wurden Leitlinien für die Behandlung und Nachsorge von TAV zusammengefasst. Ergebnisse In der Literatur wird trotz geringer Spezifität eine konventionelle Thoraxröntgenaufnahme als Initialdiagnostik genannt. Es sollte primär, als Modalität der Wahl, zur Diagnostik und zur Therapiestratifizierung eine Computertomographie (CT) aufgrund der hohen Sensitivität und Spezifität nachfolgen. In allen Leitlinien ist die thorakale endovaskuläre Aortenrekonstruktion („thoracic endovascular aortic repair“, TEVAR) die Therapie der Wahl bei höhergradigen TAV (Grade II–IV) und hat die offene Chirurgie in dem meisten Fällen abgelöst. Schlussfolgerung Nach einer kurzfristig erfolgten CT-Diagnostik und Einteilung wird die TEVAR der offenen Chirurgie bei therapiebedürftigen TAV vorgezogen.
Collapse
Affiliation(s)
- R M Benz
- Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz.
| | - V Makaloski
- Universitätsklinik für Herz- und Gefäßchirurgie, Inselspital, Universität Bern, Freiburgstr. 18, 3010, Bern, Schweiz
| | | | | | | |
Collapse
|
13
|
Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury. Gen Thorac Cardiovasc Surg 2021; 70:16-23. [PMID: 34137003 DOI: 10.1007/s11748-021-01661-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study sought to confirm if thoracic endovascular aortic repair (TEVAR) was an appropriate therapeutic strategy for blunt thoracic aortic injury (BTAI). METHODS Between 3/2005 and 12/2020, 104 patients with BTAI were brought to our hospital. The severity of each trauma case was evaluated using the Injury Severity Score (ISS); aortic injuries were classified as type I to IV according to Society for Vascular Surgery guidelines. Initial treatment was categorized into four groups: nonoperative management (NOM), open aortic repair (OAR), TEVAR, or emergency room thoracotomy/cardiopulmonary resuscitation (ERT/CPR). RESULTS The patients' mean age and ISS were 56.7 ± 20.9 years and 48.3 ± 20.4, respectively. Type III or IV aortic injury were diagnosed in 82 patients. The breakdown of initial treatments was as follows: NOM for 28 patients, OAR for four, TEVAR for 47, and ERT/CPR for 25. The overall early mortality rate was 32.7%. Logistic regression analysis confirmed ISS > 50 and shock on admission as risk factors for early mortality. The cumulative survival rate of all patients was 61.2% at 5 years after treatment. After initial treatment, eight patients receiving TEVAR required OAR. The cumulative rate of freedom from reintervention using TEVAR at 5 years was higher in approved devices than in custom-made devices (96.0 vs. 56.3%, p = 0.011). CONCLUSIONS Using TEVAR as an initial treatment for patients with BTAI is a reasonable approach. Patients with severe multiple traumas and shock on admission had poor early outcomes, and those treated with custom-made devices required significant rates of reintervention.
Collapse
|
14
|
Prendes CF, Stana J, Schneidwind KD, Rantner B, Konstantinou N, Bruder J, Kammerlander C, Banafsche R, Tsilimparis N. Blunt traumatic thoracic aortic injuries: a retrospective cohort analysis of 2 decades of experience. Interact Cardiovasc Thorac Surg 2021; 33:293-300. [PMID: 33778861 DOI: 10.1093/icvts/ivab067] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/11/2021] [Accepted: 02/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyse and report the changes in the management of blunt traumatic aortic injuries (BTAIs) in a single centre during the last 2 decades. METHODS A retrospective analysis of all patients diagnosed with BTAI from January 1999 to January 2020 was performed. Data were collected from electronic/digitalized medical history records. RESULTS Forty-six patients were included [median age 42.4 years (16-84 years), 71.7% males]. The predominant cause of BTAI was car accidents (54.5%, n = 24) and all patients presented with concomitant injuries (93% bone fractures, 77.8% abdominal and 62.2% pelvic injuries). Over 70% presented grade III or IV BTAI. Urgent repair was performed in 73.8% of patients (n = 31), with a median of 2.75 h between admission and repair. Thoracic endovascular repair (TEVAR) was performed in 87% (n = 49), open surgery (OS) in 10.9% (n = 5) and conservative management in 2.1% (n = 1). Technical success was 82.6% (92.1% TEVAR, 79% OS). In-hospital mortality was 19.5% (17.5% TEVAR, 40% OS). Of these, 3 died from aortic-related causes. Seven (15.2%) required an early vascular reintervention. The median follow-up was 34 months (1-220 months), with 19% of early survivors having a follow-up of >10 years. Only 1 vascular reintervention was necessary during follow-up: secondary TEVAR due to acute graft thrombosis. Of the patients who survived the initial event, 6.7% died during follow-up, none from aortic-related causes. CONCLUSIONS Even with all the described shortcomings, in our experience TEVAR for BTAI proved to be feasible and effective, with few complications and stable aortic reconstruction at mid-term follow-up. With the current technical expertise and wide availability of a variety of devices, it should be pursued as a first-line therapy in these challenging scenarios.
Collapse
Affiliation(s)
| | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital , Munich, Germany
| | | | - Barbara Rantner
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital , Munich, Germany
| | - Nikolaos Konstantinou
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital , Munich, Germany
| | - Jan Bruder
- Department of Trauma Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | | | - Ramin Banafsche
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital , Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital , Munich, Germany
| |
Collapse
|
15
|
Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients. Ann Vasc Surg 2021; 75:341-348. [PMID: 33556520 DOI: 10.1016/j.avsg.2021.01.096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The administration of unfractionated heparin (UFH) during endovascular repair of blunt traumatic aortic injury (BTAI) is controversial. The aim of the study is to report the early outcomes of patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI, and to assess the individualized intraoperative use and dose of UFH. METHODS This is a retrospective analysis including consecutive patients treated with TEVAR for BTAI of the descending aorta between January 1st, 2005 and December 31st, 2018. Intraoperative use and doses of UFH were analyzed. Primary outcome included a reintervention because of new onset bleeding and/or thromboembolic complication and 30-day mortality. Technical success, injury severity score (ISS), timing of treatment, and neurologic deterioration were secondary outcome. RESULTS Thirty-six patients with a mean age of 47 ± 18 years, 30 males (83%), were included. Intraoperative administration of UFH was recorded in 30/36 patients (83%) with a mean dose of 4750 ± 2180 IU. Two patients had no UFH because of extensive intracranial hemorrhage or suspected relevant liver laceration, respectively; 1 died in theatre, 1 was already anticoagulated having a mechanical aortic valve, and in 2 no information about heparin use was found. During 30 days of follow-up, 3 patients died (8%; 3/36): 1 patient with completely transected aorta died on-table and 2 on the fifth postoperative day, 1 from trauma-associated brain injury and 1 with multi organ failure. No bleeding or thromboembolic complication requiring reintervention occurred in any patient during 30 days follow-up. In 3 patients partial unintentional coverage of the left common carotid artery occurred, resulting in technical success of 89% (32/36). Mean ISS was 43 ± 15. Thirty-five patients (97%) were severely injured having an ISS ≥ 25. Twenty-nine patients (81%) were treated within 24 hr and 6 patients (17%) within 1 week. No stroke or spinal cord ischemia was observed. CONCLUSIONS Systemic heparinization in different doses during TEVAR for BTAI can be safe with no intraoperative bleeding or thromboembolic complications in early postoperative period.
Collapse
|
16
|
Cassidy S, Allouni K, Day C, Wells D, Pherwani A, Ablett D. Blunt Thoracic Aortic Injury and Acute Trauma: The Effect on Aortic Diameter and the Consequences for Stent-graft Sizing. Ann Vasc Surg 2020; 72:563-570. [PMID: 33227478 DOI: 10.1016/j.avsg.2020.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) is associated with a high mortality and large trauma burden. Trauma and resuscitation after injury affect cardiovascular status, which may in turn affect aortic diameter. Measurement of aortic diameter is necessary to guide stent-graft sizing as part of BTAI management. Inaccurate measurement may lead to stent-graft complications. This pilot study aimed to assess the effect of acute major trauma on stent-graft sizing and stent-graft complications, in the context of BTAI and to assess whether any effect could be predicted. METHODS Patients who were admitted to a UK major trauma center between January 2007 and December 2017, and were diagnosed with BTAI, were identified. The thoracic aortic diameter was measured at six points on initial and surveillance computed tomography imaging. Data on patient demographics, admission heart rate, mean arterial pressure (MAP), and serum lactate were gathered. RESULTS Thirty-two patients were identified. Twenty met inclusion criteria. Of these, 12 were managed operatively and eight nonoperatively. The mean age was 40, the mean injury severity score was 43, and 85% were male. A mean increase in diameter between initial trauma scan and surveillance scan was noted throughout the thoracic aorta (P < 0.05). Stent-graft oversizing relative to aortic diameter changed significantly from initial trauma imaging to surveillance imaging (P < 0.05). Admission heart rate, MAP, and serum lactate were not predictive of the percentage change in aortic diameter. There were no complications at surveillance imaging (mean 45 days) or during medium term follow-up (mean 532 days). CONCLUSIONS Aortic diameter is affected by BTAI, acute major trauma, and resuscitation in a significant and variable manner. Measurements of the aorta in a patient with BTAI in the acute trauma setting should be viewed with uncertainty. A lack of complications in the short term is suggestive of a wide tolerance range regarding stent-graft sizing, but long-term results are unknown.
Collapse
Affiliation(s)
- Samuel Cassidy
- Keele University Medical School, Stoke-on-Trent, Staffordshire, UK.
| | - Kader Allouni
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Christopher Day
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - David Wells
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Arun Pherwani
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Daniel Ablett
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| |
Collapse
|
17
|
Ito H, Bessho S, Yamamoto N, Hirano K, Shomura Y, Takao M. Venopulmonary artery extracorporeal lung assist in repair of traumatic aortic injury via left thoracotomy. J Card Surg 2020; 35:3575-3577. [PMID: 33047365 DOI: 10.1111/jocs.14904] [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: 11/29/2022]
Abstract
An urgent surgery was performed for a 28-year-old man who sustained a traumatic descending thoracic aortic injury in an automobile collision. Severe respiratory failure was encountered during surgery, which did not allow for single-lung ventilation for adequate exposure of the descending aorta. We used venopulmonary artery extracorporeal lung assist by main pulmonary artery cannulation with concurrent distal aortic perfusion using a single centrifugal pump. Cannulating the easily accessible main pulmonary artery for venopulmonary artery extracorporeal lung assist is a safe and feasible technique in patients complicated with profound respiratory failure undergoing aortic surgery via left thoracotomy.
Collapse
Affiliation(s)
- Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| | - Saki Bessho
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| | - Naoki Yamamoto
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| | - Yu Shomura
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery, Mie University, Tsu, Mie, Japan
| |
Collapse
|
18
|
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
|
19
|
Hundersmarck D, van der Vliet QMJ, Winterink LM, Leenen LPH, van Herwaarden JA, Hazenberg CEVB, Hietbrink F. Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life. Eur J Trauma Emerg Surg 2020; 48:1961-1973. [PMID: 32632630 PMCID: PMC9192473 DOI: 10.1007/s00068-020-01432-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Abstract
Purpose
Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL). Methods Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population. Results Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01). Conclusion This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries. Electronic supplementary material The online version of this article (10.1007/s00068-020-01432-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Dennis Hundersmarck
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Quirine M. J. van der Vliet
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Lotte M. Winterink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| | | | | | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, Post-office 85500, 3508 GA Utrecht, The Netherlands
| |
Collapse
|
20
|
The need for more information. J Vasc Surg 2020; 71:1823-1824. [PMID: 32446505 DOI: 10.1016/j.jvs.2019.05.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/31/2019] [Indexed: 11/21/2022]
|
21
|
Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury - concepts and management. J Cardiothorac Surg 2020; 15:62. [PMID: 32307000 PMCID: PMC7169033 DOI: 10.1186/s13019-020-01101-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important. MAIN BODY Blunt thoracic aortic injury may be fatal if not diagnosed and treated expeditiously. Endovascular options allow safe and effective management of these dangerous injuries. This paper describes the overview of blunt thoracic aortic trauma, the epidemiology, presentation, diagnosis, and treatment options with a focus on endovascular management. CONCLUSION Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.
Collapse
Affiliation(s)
- Nicolas J Mouawad
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA.
| | - Joseph Paulisin
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
| | - Stephen Hofmeister
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
| | - Matthew B Thomas
- McLaren Bay Heart & Vascular, McLaren Bay Region, 1900 Columbus Avenue, 4th Floor, South Tower, Bay City, MI, 48708, USA
| |
Collapse
|
22
|
Influence of Thoracic Endovascular Repair on Aortic Morphology in Patients Treated for Blunt Traumatic Aortic Injuries: Long Term Outcomes in a Multicentre Study. Eur J Vasc Endovasc Surg 2020; 59:428-436. [DOI: 10.1016/j.ejvs.2019.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 04/03/2019] [Accepted: 05/09/2019] [Indexed: 01/16/2023]
|
23
|
Abstract
ZusammenfassungVerkehrsunfälle sind für den größten Teil der traumatischen Aortenrupturen verantwortlich, meist zusammen mit weiteren schweren Begleitverletzungen. Die prähospitale Sterblichkeit ist hoch. Bei Verdacht auf eine beteiligte Aortenverletzung, aufgrund eines hohen traumatic aortic injury scores, ist eine Computertomographie durchzuführen. Es erfolgt eine Triage der Verletzungen, und die Versorgungspriorität der Aorta richtet sich nach dem Schweregrad der Aorten- und Begleitverletzungen sowie dem Zustand des Patienten. Bis zur definitiven Versorgung der aortalen Läsion muss der Blutdruck konsequent gesenkt werden. Grad I und II können in Einzelfällen unter enger Kontrolle inital konservativ gemanagt werden. Grad III (gedeckte Ruptur) und Grad IV (freie Ruptur) benötigen eine raschestmögliche Versorgung (interventionell, chirurgisch). In ausgesuchten Fällen kann auch eine verzögerte Versorgung günstig sein.Als bevorzugte Versorgungsform hat sich die interventionelle Stentgrafttherapie etabliert.
Collapse
|
24
|
Agostinelli A, Carino D, Borrello B, Marcato C, Volpi A, Gherli T, Nicolini F. Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience. Interact Cardiovasc Thorac Surg 2019; 28:17-22. [PMID: 30007311 DOI: 10.1093/icvts/ivy211] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/03/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.
Collapse
Affiliation(s)
| | - Davide Carino
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy.,Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, CT, USA
| | - Bruno Borrello
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy
| | - Carla Marcato
- Department of Radiology, Parma University Hospital, Parma, Italy
| | - Annalisa Volpi
- 1st Anesthesia and Intensive Care Department, Parma University Hospital, Parma, Italy
| | - Tiziano Gherli
- Department of Cardiac Surgery, Parma University Hospital, Parma, Italy
| | | |
Collapse
|
25
|
Mufty H, Maleux G, Houthoofd S, Cornelissen SA, Daenens K, Bonne L, Fourneau I. The effect of TEVAR for blunt traumatic thoracic aortic injury on maximal aortic diameter: Mid- and long-term outcome. Vascular 2019; 27:411-416. [PMID: 30871442 DOI: 10.1177/1708538119836333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Thoracic endovascular aortic repair (TEVAR) has become the standard of care for blunt thoracic aortic injury (BTAI). Long-term effects of TEVAR on the aortic diameter are not well studied. This study evaluates the effect of TEVAR for BTAI on the aortic diameter in mid- and long-term follow-up. Methods All patients treated with TEVAR for BTAI between August 2000 and May 2016 were included. Maximum aortic diameter was measured at four predetermined thoracic aortic levels in the preoperative and first postoperative CT angiography (CTa) and in the last control CTa or MR angiography: 1 cm proximal (D1) and 1 cm distal to the left subclavian artery (D2), 3 cm distal to the left subclavian artery (D3) and 3 cm proximal to the celiac trunk (D4). Results A total of 27 patients (20 men, mean age 40 years (±17.55) were included. Mean follow-up time was 90 months (±48.36)). No re-interventions were needed. Mean growth of aortic diameter at level D1, D2, D3 and D4 was 0.22 mm ± 3.66, 1.79 mm ± 3.82, 0.73 mm ± 4.18 and –1.06 mm ± 2.82, respectively, when comparing last follow-up to the preoperative imaging without any statistical significant differences. When comparing the preoperative diameter with the first postoperative CT, only a statistical significant growth of 2.81 mm ± 2.69 was seen at level of D2 ( p < 0.05) Conclusion During mid- to long-term follow-up, a temporary significant increase of the maximum aortic diameter was seen at level D2 in the direct postoperative phase This increase was not associated with clinical events and suggests long-term efficacy of TEVAR after BTAI.
Collapse
Affiliation(s)
- Hozan Mufty
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- 2 Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Sabrina Houthoofd
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Kim Daenens
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lawrence Bonne
- 2 Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- 1 Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
26
|
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: 10] [Impact Index Per Article: 2.0] [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.
Collapse
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
| |
Collapse
|
27
|
Kaneyuki D, Asakura T, Iguchi A, Yoshitake A, Tokunaga C, Tochii M, Nakajima H. Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience. Eur J Cardiothorac Surg 2019; 56:5309042. [PMID: 30753390 DOI: 10.1093/ejcts/ezz023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/10/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear. METHODS From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter. RESULTS The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up. CONCLUSIONS This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.
Collapse
Affiliation(s)
- Daisuke Kaneyuki
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Toshihisa Asakura
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Atsushi Iguchi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Akihiro Yoshitake
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Chiho Tokunaga
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Masato Tochii
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Hiroyuki Nakajima
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| |
Collapse
|
28
|
Outcomes after thoracic endovascular aortic repair in patients with traumatic thoracic aortic injuries—a single-centre retrospective review. Eur Surg 2019. [DOI: 10.1007/s10353-019-0570-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
29
|
García Reyes ME, Gonçalves Martins G, Fernández Valenzuela V, Domínguez González JM, Maeso Lebrun J, Bellmunt Montoya S. Long-Term Outcomes of Thoracic Endovascular Aortic Repair Focused on Bird Beak and Oversizing in Blunt Traumatic Thoracic Aortic Injury. Ann Vasc Surg 2018; 50:140-147. [DOI: 10.1016/j.avsg.2018.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/22/2017] [Accepted: 02/08/2018] [Indexed: 10/18/2022]
|
30
|
Fontana F, Macchi E, Piacentino F, Cardim LN, Marchi GD, Barbosa F, Piffaretti G, Novario R, Rampoldi AG, Fugazzola C. The Evaluation of Aortic Diameter Changes During Long-Term Follow-Up After Endovascular Treatment of Acute Blunt Traumatic Thoracic Aortic Injuries. Vasc Endovascular Surg 2018; 52:335-343. [DOI: 10.1177/1538574418765385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To evaluate the variations in aortic diameters and long-term results in patients who underwent thoracic endovascular aortic repair (TEVAR) for acute blunt traumatic thoracic aortic injuries (BTTAIs). Materials and Methods: We retrospectively evaluated 23 patients with a mean age of 39 years (range: 17-74 years) who underwent TEVAR for BTTAI between October 2000 and November 2014. All of the patients underwent computed tomography angiography (CTA) before hospital discharge as a baseline imaging for the subsequent follow-up examinations. The technical success, overall survival, and complications were evaluated. Furthermore, the aortic diameters outside of the stent-graft (1 cm proximal and 1 cm distal to the stent-graft) and the aortic diameters within the stent-graft (2 cm distal to the proximal end and 2 cm proximal to the distal end) were assessed. The diameters at baseline on CTA were compared with those of the latest available follow-up examination. Results: Technical success was 100% with a mean follow-up of 65.4 months (range: 12-171 months). No death was registered, and 2 (8.7%) of 23 endograft-related complications (1 stent-graft distal infolding and 1 endoleak 2 and 4 months after the procedure, respectively) were observed. An increase in aortic diameter either proximal or distal to the stent-graft (mean value 0.7 and 0.5 mm, respectively) or within the stent-graft (mean value of 0.5 mm for both proximal and distal diameters) was registered (mean follow-up at 65.4 months, range: 12-171 months). Conclusion: Aortic dilatation following TEVAR for BTTAI is minimal during long-term follow-up. Endovascular treatment represents a durable and safe option in acute BTTAIs.
Collapse
Affiliation(s)
- Federico Fontana
- Department of Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | - Edoardo Macchi
- Department of Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | - Filippo Piacentino
- Department of Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | | | - Giuseppe De Marchi
- Department of Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | - Fabiane Barbosa
- Department of Radiology, Niguarda Ca’Granda Hospital, Milano, Italy
| | - Gabriele Piffaretti
- Department of Surgery and Morphological Sciences, University of Insubria, Circolo Hospital, Varese, Italy
| | - Raffaele Novario
- Department of Clinical and Biological Sciences, University of Insubria,Circolo Hospital, Varese, Italy
| | | | - Carlo Fugazzola
- Department of Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| |
Collapse
|
31
|
Stringel G, Xu ML, Erb M. Endovascular repair of blunt thoracic aortic injury. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
32
|
Novo Martínez G, Ortega Martín J, Samos RF, Pomar MB, Calvo AZ. Tratamiento endovascular de lesión iatrogénica en aorta torácica causada por tornillo de artrodesis. ANGIOLOGIA 2018. [DOI: 10.1016/j.angio.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
33
|
Ghazy T, Mikulasch S, Reeps C, Hoffmann RT, Wijatkowska K, Diab AH, Kappert U, Matschke K, Weiss N, Mahlmann A. Experts' Results in Blunt Thoracic Aortic Injury are Reproducible in Lower Volume Tertiary Institutions. Early and Mid-term Results of an Observational Study. Eur J Vasc Endovasc Surg 2017; 54:604-612. [PMID: 28958467 DOI: 10.1016/j.ejvs.2017.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 08/09/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the early and mid-term clinical results, the device performance, and the mid-term re-intervention rates of patients suffering blunt thoracic aortic injury (BTAI) managed by a multidisciplinary team in a low-volume BTAI centre. METHODS This was a retrospective observational study in a tertiary hospital setting. From December 2005 to March 2016, all patients over 18 years old admitted with BTAI were included in the study. No exclusion criteria were applied. The study data were collected and analysed retrospectively. Follow-up of survivors included computed tomography imaging 3 and 9 months post-procedure, then annually. RESULTS Twenty-eight patients were included in the study. Their mean age was 42 ± 16 years and 89% were male. A contained aortic rupture was diagnosed in 20 patients, a Stanford type B dissection in six, and intramural haematoma in two patients. Multidisciplinary evaluations were performed and an intervention was indicated in 25 patients (89%), four of whom died before the intervention. Nineteen patients underwent thoracic endovascular aortic repair of the descending thoracic aorta and two patients underwent a frozen elephant trunk procedure. The procedures were performed 0.7 ± 1.2 days after injury. All procedures were successful. There were no device related complications. The post-operative 30 day mortality was 5%, with one patient dying on the day of operation from other vascular injuries. The 30 day mortality of all patients was 18%. The median mid-term follow-up period was 786 days. All 30 day survivors survived the follow-up period. The mid-term imaging showed stable results in 19 patients. Two patients required frozen elephant trunk procedures after 240 and 681 days and both procedures were successful. CONCLUSIONS In a low volume centre, a multidisciplinary team using a standardised protocol with the endovascular first approach demonstrated excellent outcomes, similar to those of large centres. If the aortic trauma is adequately managed, the patient's outcome is closely related to the additional trauma.
Collapse
Affiliation(s)
- Tamer Ghazy
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany.
| | - Sandra Mikulasch
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christian Reeps
- University Centre for Vascular Medicine and Department of Vascular Surgery, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- University Centre for Vascular Medicine and Institute for Diagnostic Radiology, University Hospital Carl Gustav Carus Dresden, Dresden University of Technology, Dresden, Germany
| | - Kasia Wijatkowska
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Abdel-Hannan Diab
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery of the Dresden Heart Centre University Hospital, Dresden University of Technology, Dresden, Germany
| | - Norbert Weiss
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Adrian Mahlmann
- University Centre for Vascular Medicine and Division of Angiology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Martin C, Thony F, Rodiere M, Bouzat P, Lavagne P, Durand M, Chavanon O. Long-term results following emergency stent graft repair for traumatic rupture of the aortic isthmus†. Eur J Cardiothorac Surg 2017; 51:767-772. [DOI: 10.1093/ejcts/ezw369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/10/2016] [Indexed: 01/16/2023] Open
|
36
|
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, Czerny M, Fraedrich G, Haulon S, Jacobs M, Lachat M, Moll F, Setacci C, Taylor P, Thompson M, Trimarchi S, Verhagen H, Verhoeven E, ESVS Guidelines Committee, Kolh P, de Borst G, Chakfé N, Debus E, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Document Reviewers, Kolh P, Black J, Busund R, Björck M, Dake M, Dick F, Eggebrecht H, Evangelista A, Grabenwöger M, Milner R, Naylor A, Ricco JB, Rousseau H, Schmidli J. Editor's Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg 2017; 53:4-52. [DOI: 10.1016/j.ejvs.2016.06.005] [Citation(s) in RCA: 598] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
37
|
Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64:1580-1586. [DOI: 10.1016/j.jvs.2016.05.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
|
38
|
Khashram M, He Q, Oh TH, Khanafer A, Wright IA, Vasudevan TM, Lo ASN, Roake JA, Civil I. Late Radiological and Clinical Outcomes of Traumatic Thoracic Aortic Injury Managed with Thoracic Endovascular Aortic Repair. World J Surg 2016; 40:1763-70. [DOI: 10.1007/s00268-016-3457-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
39
|
Ultee KHJ, Soden PA, Chien V, Bensley RP, Zettervall SL, Verhagen HJM, Schermerhorn ML. National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries. J Vasc Surg 2016; 63:1232-1239.e1. [PMID: 26776898 DOI: 10.1016/j.jvs.2015.11.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally. METHODS Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3). CONCLUSIONS TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.
Collapse
Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Victor Chien
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Rodney P Bensley
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
| |
Collapse
|