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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.
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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
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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: 8] [Impact Index Per Article: 8.0] [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
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Mistry R, Moore J. Management of blunt thoracic trauma. BJA Educ 2022; 22:432-439. [PMID: 36304913 PMCID: PMC9596286 DOI: 10.1016/j.bjae.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 10/31/2022] Open
Affiliation(s)
- R.N. Mistry
- Gold Coast University Hospital, Southport, QLD, Australia
| | - J.E. Moore
- Wellington Regional Hospital, Wellington, New Zealand
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4
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Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology 2022; 73:497-507. [DOI: 10.1177/00033197211052131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.
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Affiliation(s)
- Ranjan Dahal
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Alan H. Tyroch
- Department of Surgery, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
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Lee J, Ye J, Lee J, Kim S, Choi H, Kim Y, Yoon S, Sul Y, Choi J. Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution. Int J Crit Illn Inj Sci 2022; 12:101-105. [PMID: 35845121 PMCID: PMC9285127 DOI: 10.4103/ijciis.ijciis_89_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/08/2021] [Accepted: 01/01/2022] [Indexed: 12/04/2022] Open
Abstract
Background: We aimed to investigate the outcomes after delayed management of ≥ Grade II blunt traumatic thoracic aortic injury (BTAI). Methods: Between January 2005 and December 2019, we retrospectively reviewed the medical records of 21 patients with ≥ Grade II thoracic aortic injury resulting from blunt trauma. Twelve patients underwent observation for the injury, whereas nine patients were transferred immediately after the diagnosis. Patients were divided into a nonoperative management group (n = 7) and delayed repair group (n = 5) based on whether they underwent thoracic endovascular aneurysm repair or surgery. Results: The most common dissection type was DeBakey classification IIIa (n = 9). Five patients underwent delayed surgery (including aneurysm repair), with observation periods ranging from 1 day to 36 months. The delayed repair group exhibited higher injury severity scores than the nonoperative management group (n = 7). The nonoperative management group was followed-up with blood pressure management without a change in status for a period ranging from 3 to 96 months. Conclusions: Our findings indicated that conservative management may be appropriate for select patients with Grade II/III BTAI, especially those exhibiting hemodynamic stability with anti-impulse therapy and minimally sized pseudoaneurysms. However, further studies are required to identify the risk factors for injury progression and long-term outcomes.
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Brown SR, Still SA, Eudailey KW, Beck AW, Gunn AJ. Acute traumatic injury of the aorta: presentation, diagnosis, and treatment. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1193. [PMID: 34430634 PMCID: PMC8350653 DOI: 10.21037/atm-20-3172] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022]
Abstract
Despite advances in detection and treatment, acute traumatic aortic injury (ATAI) is associated with high rates of morbidity and mortality. Both physical and hemodynamic forces have been postulated as mechanisms of aortic injury during a traumatic event. For patients who survive the initial injury, rapid detection is critical for diagnosis and procedural planning, which requires a thorough knowledge of both its clinical presentation and the available diagnostic imaging modalities. Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) can each have a role in the diagnosis of ATAI. After stabilization of the patient, the management of ATAI is guided by the severity of injury. Appropriately selected patients with low grade injuries may be managed non-operatively. When treatment is required, there are both open surgical and endovascular options. In current practice, endovascular approaches with stent-graft placement are preferred due to their high clinical success and low rates of complications. Complications from endograft placement can include: endoleak, endograft collapse, infection, endograft failure, and endograft migration. Open surgical repair is now reserved for patients with unfavorable anatomy for endovascular therapies. This review provides a comprehensive overview of ATAI including its epidemiology and demographics, mechanisms of injury, clinical and radiographic diagnosis, treatment options, and post-therapeutic follow-up.
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Affiliation(s)
- S Rodes Brown
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sasha A Still
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew J Gunn
- Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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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.
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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
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D'Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, Trimarchi S. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:681-696. [PMID: 32964899 DOI: 10.23736/s0021-9509.20.11580-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
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Affiliation(s)
- Ilenia D'Alessio
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Bissacco
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierantonio Rimoldi
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno Palmieri
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Gaffey AC, Zhang J, Saka E, Quatromoni JG, Glaser J, Kim P, Szeto W, Kalapatapu V. Natural History of Nonoperative Management of Grade II Blunt Thoracic Aortic Injury. Ann Vasc Surg 2020; 65:124-129. [DOI: 10.1016/j.avsg.2019.10.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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Kaneyuki D, Asakura T, Iguchi A, Yoshitake A, Tokunaga C, Tochii M, Nakajima H. Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience. Eur J Cardiothorac Surg 2019; 56:5309042. [PMID: 30753390 DOI: 10.1093/ejcts/ezz023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/10/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear. METHODS From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter. RESULTS The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up. CONCLUSIONS This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.
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Affiliation(s)
- Daisuke Kaneyuki
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Toshihisa Asakura
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Atsushi Iguchi
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Akihiro Yoshitake
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Chiho Tokunaga
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Masato Tochii
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
| | - Hiroyuki Nakajima
- Division of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka-shi, Japan
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Tsai R, Raptis D, Raptis C, Mellnick VM. Traumatic abdominal aortic injury: clinical considerations for the diagnostic radiologist. Abdom Radiol (NY) 2018; 43:1084-1093. [PMID: 29492608 DOI: 10.1007/s00261-018-1523-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumatic abdominal aortic injury (TAAI) is a severe complication of penetrating and blunt trauma with significant morbidity and mortality, particularly if diagnosis is delayed. In patients with life-threatening injuries, accurate and prompt diagnosis of TAAI can be made with computed tomography (CT). Once the diagnosis of TAAI is made, the radiologist should provide an accurate description of the aortic lesion and the extent of injury in order to guide management whether it be non-operative, open aortic repair, or endoluminal stent repair. The purpose of this article is to review the key imaging aspects of TAAI and to discuss how the key CT imaging findings affect clinical management.
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Affiliation(s)
- Richard Tsai
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway, St. Louis, MO, 63108, USA.
| | - Demetrios Raptis
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway, St. Louis, MO, 63108, USA
| | - Constantine Raptis
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway, St. Louis, MO, 63108, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S. Kingshighway, St. Louis, MO, 63108, USA
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12
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Imaging of Acute Traumatic Aortic Injury. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0278-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Sandhu HK, Leonard SD, Perlick A, Saqib NU, Miller CC, Charlton-Ouw KM, Safi HJ, Azizzadeh A. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg 2018; 67:389-398. [DOI: 10.1016/j.jvs.2017.07.111] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022]
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Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis. J Trauma Acute Care Surg 2018. [PMID: 28640779 DOI: 10.1097/ta.0000000000001630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM. METHODS The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests. RESULTS A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR. CONCLUSIONS Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Martin C, Thony F, Rodiere M, Bouzat P, Lavagne P, Durand M, Chavanon O. Long-term results following emergency stent graft repair for traumatic rupture of the aortic isthmus†. Eur J Cardiothorac Surg 2017; 51:767-772. [DOI: 10.1093/ejcts/ezw369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/10/2016] [Indexed: 01/16/2023] Open
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Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64:1580-1586. [DOI: 10.1016/j.jvs.2016.05.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
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17
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Harris DG, Rabin J, Starnes BW, Khoynezhad A, Conway RG, Taylor BS, Toursavadkohi S, Crawford RS. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg 2016; 64:500-505. [DOI: 10.1016/j.jvs.2015.12.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/19/2015] [Indexed: 10/21/2022]
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18
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Harris DG, Rabin J, Bhardwaj A, June AS, Oates CP, Garrido D, Toursavadkohi S, Khoynezhad A, Crawford RS. Nonoperative Management of Traumatic Aortic Pseudoaneurysms. Ann Vasc Surg 2016; 35:75-81. [PMID: 27263820 DOI: 10.1016/j.avsg.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current blunt thoracic aortic injury (BTAI) guidelines recommend early repair of traumatic pseudoaneurysms (PSAs) due to risk for subsequent aortic rupture. Recent analyses indicate that early repair is required only in the setting of high-risk features, while delayed repair is safe and associated with lower morbidity and mortality in appropriately selected patients. To evaluate the appropriate indications for nonoperative management (NOM) of traumatic PSAs, we performed a systematic review of studies reporting outcomes for this management strategy. We hypothesized that NOM is safe in appropriately selected patients with traumatic aortic PSAs. METHODS English language single- and multi-institutional series reporting NOM of traumatic thoracic aortic PSAs were identified by systematic literature search and review. A descriptive analysis was performed of NOM, with stratification by lesion size and patient follow-up. The primary outcomes were late aortic intervention, aortic-related death, and all-cause mortality. RESULTS Eighteen studies, which included 937 patients with traumatic PSAs, were analyzed. One hundred ninety-one patients were managed nonoperatively. The primary indication for NOM was prohibitive risk for aortic repair due to severe comorbidities or concurrent injuries. Where reported, PSAs with <50% circumferential involvement accounted for 88% of lesions selected for NOM. Late interventions were required in 4% of patients. Inpatient aortic-related mortality was 2%, and all-cause inpatient mortality was 32%. Although survival at up to 4-7 years was reported, postdischarge follow-up after PSA NOM was limited to <1 year in most studies. CONCLUSIONS NOM of traumatic aortic PSAs is a common practice in BTAI series reporting lesion-specific management, and is associated with low rates of treatment failure. These findings suggest that routine early repair may not be required for traumatic PSAs, particularly for lesions limited to <50% of the aortic circumference. Definitive repair can be delayed until patient stability and repair timing can be guided by assessment of lesion stability on follow-up imaging.
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Affiliation(s)
- Donald G Harris
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Joseph Rabin
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Abhishek Bhardwaj
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Angelina S June
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Connor P Oates
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Danon Garrido
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ali Khoynezhad
- Division of Cardiothoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert S Crawford
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
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Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Nakanishi T, Ishida H. Blunt thoracic aortic injury with small pseudoaneurysm may be managed by nonoperative treatment. J Vasc Surg 2015; 63:341-4. [PMID: 26506935 DOI: 10.1016/j.jvs.2015.08.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The efficacy of nonoperative management of blunt thoracic aortic injury (BTAI) was evaluated in patients with pseudoaneurysm. METHODS A retrospective review was done for patients with BTAI at Fukui Prefectural Hospital during a 9-year period. Charts were reviewed for age, gender, Injury Severity Score, Abbreviated Injury Scale for each body area, initial type of aortic injury, site of aortic injury, type of definitive management, complications, and outcomes. RESULTS Eighteen patients with BTAI were treated at Fukui Prefectural Hospital. Of 18 patients with pseudoaneurysm, seven patients were hemodynamically unstable and four patients died because of associated injuries; there were no aortic-related deaths. All 14 surviving patients were followed up for an average of 40.9 months. Only two patients with pseudoaneurysm required operative management because of the progression of the pseudoaneurysm. The pseudoaneurysm/normal aortic diameter ratio of those with any intervention was higher than that of those with nonoperative management. CONCLUSIONS BTAI with pseudoaneurysm can be managed nonoperatively, with about 10% risk of progression to require surgical repair.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Aneurysm, False/diagnosis
- Aneurysm, False/mortality
- Aneurysm, False/physiopathology
- Aneurysm, False/therapy
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/physiopathology
- Aorta, Thoracic/surgery
- Aortography/methods
- Disease Progression
- Female
- Hemodynamics
- Humans
- Injury Severity Score
- Japan
- Male
- Middle Aged
- Retrospective Studies
- Thoracic Injuries/diagnosis
- Thoracic Injuries/mortality
- Thoracic Injuries/physiopathology
- Thoracic Injuries/therapy
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
- Vascular System Injuries/diagnosis
- Vascular System Injuries/mortality
- Vascular System Injuries/physiopathology
- Vascular System Injuries/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/physiopathology
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan.
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Makoto Sera
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideya Nagai
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Taizo Nakanishi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Ishida
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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Iddriss A, Ziganshin BA, Tranquilli M, Elefteriades JA. Chronic Traumatic Thoracic Aortic Aneurysm: 40-Year Follow-Up. J Card Surg 2015; 30:586-8. [DOI: 10.1111/jocs.12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Iddriss
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
- Department of Surgical Diseases # 2; Kazan State Medical University; Kazan Russia
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital; Yale University School of Medicine; New Haven Connecticut
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Forcillo J, Philie M, Ojanguren A, Le Guillan S, Verdant A, Demers P, Lamarche Y. Outcomes of Traumatic Aortic Injury in a Primary Open Surgical Approach Paradigm. Trauma Mon 2015; 20:e18198. [PMID: 26290856 PMCID: PMC4538729 DOI: 10.5812/traumamon.18198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/28/2014] [Accepted: 07/12/2014] [Indexed: 11/30/2022] Open
Abstract
Background: Multiple classifications can be used to define the magnitude of aortic injury. The Vancouver Classification (VC) is a new and simplified computed tomography-based Blunt Aortic Injury (BAI) grading system correlating with clinical outcomes. Objectives: The objectives of this study are: 1) to describe the severity of aortic injury in a center with a predominantly surgical approach to BAI; 2) to correlate the severity of aortic trauma to hospital survival rate and rate of adverse events according to the type of interventions performed during the hospital stay; and 3) to evaluate VC. Patients and Methods: All patients referring to the Sacre-Coeur Hospital of Montreal between August 1998 and April 2011 for management of BAI were studied. Two radiologists reviewed all CT scan images individually and classified the aortic injuries using VC. Results: Among the 112 patients presenting with BAI, 39 cases had local CT scans available for reconstruction. Seven patients were identified as suffering from grade I injuries (flap or thrombus of less than 1 cm), 6 from grade II injuries (flap or thrombus of more than 1 cm), and 26 from grade III injuries (pseudoaneurysm). Among the patients with grade I injuries, 57% were treated surgically and 43% medically with a survival rate of 100%. Among the patients with grade II injuries (67% treated surgically and 33% treated medically) survival was also 100%. Among patients with grade III injuries (85% treated surgically, 7% had Thoracic Endovascular Aortic Repair (TEVAR) and 8% treated medically) survival was 95%, 95% and 50%, respectively. There were no significant differences between groups as to clinical outcome. Inter-rater reliability was 0.81. Conclusions: VC is easy to use and has low inter-observer variability. Low grades of injury were associated with low mortality related to medical treatment.
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Affiliation(s)
- Jessica Forcillo
- Division of Cardiovascular Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
| | - Michel Philie
- Division of Radiology, Sacre-Coeur Hospital of Montreal, Montreal, Canada
| | - Andrea Ojanguren
- Division of Radiology, Sacre-Coeur Hospital of Montreal, Montreal, Canada
| | - Soazig Le Guillan
- Division of Traumatology/General Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
| | - Alain Verdant
- Division of Cardiovascular Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Division of Traumatology/General Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
| | - Philippe Demers
- Division of Cardiovascular Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Division of Traumatology/General Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Yoan Lamarche
- Division of Cardiovascular Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Division of Traumatology/General Surgery, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Canada
- Critical Care Medicine, Sacre-Coeur Hospital of Montreal, Montreal, Canada
- Corresponding author: Yoan Lamarche, Department of Cardiac Surgery, Montreal Heart Institute, 5000 Rue Belanger, Montreal, Quebec, H1T 1C8, Canada. Tel: +514-3763330, Fax: +514-5932157, E-mail:
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23
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Meyer C, Engelbrecht A. Traumatic aortic dissection presenting with respiratory arrest. Afr J Emerg Med 2015. [DOI: 10.1016/j.afjem.2014.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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24
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Harris DG, Rabin J, Kufera JA, Taylor BS, Sarkar R, O'Connor JV, Scalea TM, Crawford RS. A new aortic injury score predicts early rupture more accurately than clinical assessment. J Vasc Surg 2014; 61:332-8. [PMID: 25195146 DOI: 10.1016/j.jvs.2014.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/01/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
| | - Joseph Rabin
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Joseph A Kufera
- National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Bradley S Taylor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - Rajabrata Sarkar
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
| | - James V O'Connor
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Thomas M Scalea
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md; National Study Center; Shock, Trauma and Anesthesiology Research Center, University of Maryland Medical Center, Baltimore, Md
| | - Robert S Crawford
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, Md
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25
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Kohli S, Yadav N, Singh GP, Prabhakar H. Permissive hypotension in traumatic brain injury with blunt aortic injury: How low can we go? J Anaesthesiol Clin Pharmacol 2014; 30:406-8. [PMID: 25190954 PMCID: PMC4152686 DOI: 10.4103/0970-9185.137279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
With an ever-increasing incidence of high impact collisions, polytrauma is becoming increasingly common. Patients with traumatic brain injury (TBI) may require urgent surgical intervention along with maintenance of an adequate mean arterial pressure (MAP) to maintain cerebral perfusion. On the other hand, patients who sustain blunt aortic injuries (BAI) have a high mortality rate, many of them succumbing to their injury at the site of trauma. Surgery has been the mainstay of the management strategy for the remaining survivors. However, in recent years, the paradigm has shifted from early operative management to conservative treatment with aggressive blood pressure and heart rate control, serial imaging, and close clinical monitoring. When TBI and BAI coexist in a patient, it becomes crucial to maintain the MAP within a narrow range to prevent secondary insult to the brain as well as to prevent aortic rupture. We present the management of a case of TBI with traumatic aortic pseudoaneurysm, which required stringent monitoring and maintenance of hemodynamics during decompressive craniectomy.
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Affiliation(s)
- Santvana Kohli
- Department of Anesthesiology, JPN Apex Trauma Centre, New Delhi, India
| | - Naveen Yadav
- Department of Anesthesiology, JPN Apex Trauma Centre, New Delhi, India
| | - Gyaninder Pal Singh
- Department of Neuroanesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanesthesiology, All India Institute of Medical Sciences, New Delhi, India
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26
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Rabin J, Harris DG, Crews GA, Ho M, Taylor BS, Sarkar R, O'Connor JV, Scalea TM, Crawford RS. Early Aortic Repair Worsens Concurrent Traumatic Brain Injury. Ann Thorac Surg 2014; 98:46-51; discussion 51-2. [DOI: 10.1016/j.athoracsur.2014.04.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/28/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
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Jacks R, Degiannis E. Endovascular Therapy And Controversies In The Management Of Vascular Trauma. Scand J Surg 2014; 103:149-155. [DOI: 10.1177/1457496914532248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: To review the advent of endovascular treatment of vascular injuries and its controversies. Methods: Literature review over the past 13 years using the PubMed search engine. Results: The management of vascular trauma has changed dramatically over the last decade. This is mainly due to the advent of advanced endovascular techniques and technologies. There are, however, a limited number of publications with a correspondingly small number of patients and lack of long-term follow-up. In this article, we discuss the injuries to different vessel groups and their respective endovascular approaches. Of the literature available, the endovascular management of aortic injuries still holds the most experience and has shown favorable results. Conclusion: Endovascular management of vascular injuries is a new addition to the armamentarium of the surgeon. The fact that it is minimally invasive is a major advantage and the published data are encouraging. However, in order to determine which anatomical sites and circumstances are most appropriate for this method versus open surgery, more reports are necessary.
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Affiliation(s)
- R. Jacks
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Milpark Hospital, Johannesburg, South Africa
| | - E. Degiannis
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Milpark Hospital, Johannesburg, South Africa
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28
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Parameters for successful nonoperative management of traumatic aortic injury. J Thorac Cardiovasc Surg 2014; 147:143-9. [DOI: 10.1016/j.jtcvs.2013.08.053] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/30/2013] [Accepted: 08/15/2013] [Indexed: 11/22/2022]
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29
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Osgood MJ, Heck JM, Rellinger EJ, Doran SL, Garrard CL, Guzman RJ, Naslund TC, Dattilo JB. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg 2013; 59:334-41. [PMID: 24342065 DOI: 10.1016/j.jvs.2013.09.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury. Therefore, we conducted a retrospective observational analysis of our experience with these patients. METHODS We retrospectively reviewed all BAI presenting to an academic level I trauma center over a 10-year period (2000-2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded. RESULTS We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries or aortic dissection, and were excluded from this analysis. The remaining 49 patients had 50 grade I-II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and four grade II injuries (intramural hematoma, 5%) nonoperatively. Of these, 41 patients had follow-up imaging at a mean of 86 days postinjury and constitute our study cohort. Mean age was 41 years, and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining two (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and two (5%) had progression of injury. Of the two patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up. CONCLUSIONS Injury progression in grade I-II BAI is rare (~5%) and did not cause death in our study cohort. Given that progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Aneurysm, False/etiology
- Aneurysm, False/therapy
- Aorta, Abdominal/drug effects
- Aorta, Abdominal/injuries
- Aorta, Abdominal/surgery
- Aorta, Thoracic/drug effects
- Aorta, Thoracic/injuries
- Aorta, Thoracic/surgery
- Aortic Aneurysm/etiology
- Aortic Aneurysm/therapy
- Aortography/methods
- Cardiovascular Agents/therapeutic use
- Disease Progression
- Endovascular Procedures
- Female
- Humans
- Injury Severity Score
- Length of Stay
- Male
- Middle Aged
- Retrospective Studies
- Risk Factors
- Time Factors
- Tomography, Spiral Computed
- Trauma Centers
- Treatment Outcome
- Vascular System Injuries/diagnosis
- Vascular System Injuries/mortality
- Vascular System Injuries/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Michael J Osgood
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
| | - Josh M Heck
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Eric J Rellinger
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Stacey L Doran
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - C Louis Garrard
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas C Naslund
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jeffery B Dattilo
- Department of Surgery Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, Tenn
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30
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31
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Harris DG, Drucker CB, Brenner ML, Sarkar R, Narayan M, Crawford RS. Patterns and management of blunt abdominal aortic injury. Ann Vasc Surg 2013; 27:1074-80. [PMID: 23790766 DOI: 10.1016/j.avsg.2012.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 08/28/2012] [Accepted: 09/04/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blunt abdominal aortic injury (BAAI) is historically associated with significant morbidity and mortality. Our institutional experience was analyzed to define current patterns of injury and to help guide management. METHODS Adult patients with BAAI between January 2000 and July 2011 were identified from our trauma registry. Medical, radiographic, and autopsy records were reviewed for relevant clinical data. Management and outcomes were compared between patients with minimal aortic injury limited to the intima (MAI) compared to more significant aortic injury (SAI). RESULTS Nine patients had MAI and 8 had SAI, including 2 dissections, 2 pseudoaneurysms, 2 branch avulsions, 1 thrombosis, and 1 transection. The MAI and SAI groups had similar demographics and patterns of injury, and all patients had significant polytrauma, with a mean injury severity score of 42. More MAI than SAI patients were managed nonoperatively (100% vs. 38%; P=0.01). All observed patients underwent repeat imaging during the index admission, 85% within 72 hours, and no observed lesions led to malperfusion, death, or progression during the index admission. One MAI progressed to a pseudoaneurysm within 8 months. Five SAI patients underwent aortic-related repairs, including 2 endovascular stent grafts, 2 open primary repairs, and 1 axillobifemoral bypass. Overall, 15 (88%) patients underwent procedures for any injury-9 required laparotomy (53%) and 2 underwent thoracotomy. There were 6 (35%) deaths, 2 attributable to aortic injury-1 from hemorrhage and 1 from hyperkalemic cardiac arrest after prolonged ischemia from infrarenal aortic occlusion. Among patients who survived the initial resuscitation, SAI was associated with a significantly higher mortality rate compared to MAI (50% vs. 0%; P=0.03). CONCLUSIONS Patients with MAI are at low risk of complications and may be considered for observation. Patients with SAI requiring intervention manifest clinically and/or radiographically at presentation. Those not associated with bleeding, malperfusion, or thromboembolism may be observed with interval imaging. For all observed patients, long-term surveillance is required to document complete resolution or stability, because even MAI can progress to a more complex lesion.
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32
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Kidane B, Parry NG, Forbes TL. Review of the management of blunt thoracic aortic injuries according to current treatment recommendations. Ann Vasc Surg 2013; 27:1014-9. [PMID: 23790764 DOI: 10.1016/j.avsg.2012.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 08/26/2012] [Accepted: 09/16/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) is associated with high mortality. Recent Society for Vascular Surgery (SVS) guidelines recommend repair of all but SVS grade I injuries. This study's objective was to retrospectively determine guideline adherence at the authors' trauma center, and its impact on mortality. METHODS A retrospective review of the trauma database at the authors' university-affiliated trauma center identified and graded all BTAIs between 1999 and 2011. Patient demographics, treatment, and outcomes were recorded. RESULTS Imaging was available for 52 of 59 (85.2%) patients with BTAI. For these 52 patients, injury distribution was: 14 (27.0%) grade 1; 1 (1.9%) grade 2; 35 (67.3%) grade 3; and 2 (3.8%) grade 4. Nonoperative management was used for 92.8% (13), 100% (1), 34.3% (12), and 0% of grade 1, 2, 3, and 4 injuries, respectively. The operatively managed grade I injury was initially misclassified as grade 3. He was lost to follow-up after discharge. Of the 12 patients with nonoperatively managed grade 3 injuries, 7 (58.3%) died before consideration of endovascular repair and another died early secondary to brain injury. The remaining 4 (11.4%) with nonoperatively managed grade 3 injuries survived to discharge but were lost to follow-up. For grade 3 injuries, endovascular repair was significantly associated with decreased mortality (odds ratio [OR], 0.10; 0.02-0.53; P=0.007). Exclusion of those with presentation-day mortality negated this significant association (OR, 0.84; 0.07-9.68; P=1.00). CONCLUSIONS Minor deviation (9.6%) from guidelines did not result in additional morbidity/mortality. However, a high rate of loss to follow-up limits conclusions. The mortality reduction seen with endovascular repair for grade 3 injury is inflated by patients who die before repair is considered in the nonoperative group. Larger prospective studies with appropriate inclusion and exclusion criteria and improved follow-up are needed to determine the consequences of selective nonoperative management of these injuries.
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Affiliation(s)
- Biniam Kidane
- Division of General Surgery, London Health Sciences Centre & University of Western Ontario, London, Ontario, Canada
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Cho JW, Kwon OC, Lee S, Jang JS. Traumatic Aortic Injury: Single-center Comparison of Open versus Endovascular Repair. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 45:390-5. [PMID: 23275921 PMCID: PMC3530723 DOI: 10.5090/kjtcs.2012.45.6.390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 08/01/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
Abstract
Background Conventional open repair is a suboptimal therapy for blunt traumatic aortic injury (BTAI) due to the high postoperative mortality and morbidity rates. Recent advances in the thoracic endovascular repair technique may improve outcomes so that it becomes an attractive therapeutic option. Materials and Methods From August 2003 to March 2012, 21 patients (mean age, 45.81 years) with BTAI were admitted to our institution. Of these, 18 cases (open repair in 11 patients and endovascular repair in 7 patients) were retrospectively reviewed and the early perioperative results of the two groups were compared. Results Although not statistically significant, there was a trend toward the reduction of mortality in the endovascular repair group (18.2% vs. 0%). There were no cases of paraplegia or endoleak. Statistically significant reductions in heparin dosage, blood loss, and transfusion amounts during the operations and in procedure duration were observed. Conclusion Compared with open repair, endovascular repair can be performed with favorable mortality and morbidity rates. However, relatively younger patients who have acute aortic arch angulation and a small aortic diameter may be a therapeutic challenge. Improvements in graft design, delivery sheaths, and graft durability are the cornerstone of successful endovascular repair.
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Affiliation(s)
- Jun Woo Cho
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine, Korea
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Malgor RD, Bilfinger TV, McCormack J, Shapiro MJ, Tassiopoulos AK. Trends in Clinical Presentation, Management, and Mortality of Blunt Aortic Traumatic Injury Over an 18-Year Period. Vasc Endovascular Surg 2012; 47:19-23. [DOI: 10.1177/1538574412469286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The purpose of our study was to assess whether the trends in management of blunt thoracic aortic injury (BTAI) have changed its outcomes over the years. Methods: We reviewed data of 88 (0.3%) adult patients with BTAI from January 1993 to December 2010. Primary end points were trends in presentation and time to repair and early morbidity and mortality. Results: Of all, 63 (72%) patients with BTAI were male (age, 38 ± 17). The yearly distribution of cases and severity of associated injuries remain stable. Of all, 16 (21%) patients had no intervention, 47 (63%) underwent open repair, and 12 (16%) underwent endovascular treatment. The postoperative mortality has decreased from 29% to 9% and the time from presentation to repair has increased from 6 to 14 hours during the study period. Conclusions: The incidence of BTAI remains stable with a reduction in postoperative mortality rate and an increasing number of delayed interventions over the past 18 years.
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Affiliation(s)
- Rafael D. Malgor
- Division of Vascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Thomas V. Bilfinger
- Division of Cardiothoracic Surgery, Department of Surgery, Stony Brook, NY, USA
| | - Jane McCormack
- Division of Trauma/Surgical Critical Care, Department of Surgery, Stony Brook, NY, USA
| | - Marc J. Shapiro
- Division of Trauma/Surgical Critical Care, Department of Surgery, Stony Brook, NY, USA
| | - Apostolos K. Tassiopoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
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Kidane B, Abramowitz D, Harris JR, DeRose G, Forbes TL. Natural history of minimal aortic injury following blunt thoracic aortic trauma. Can J Surg 2012; 55:377-81. [PMID: 22992400 PMCID: PMC3506686 DOI: 10.1503/cjs.007311] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2011] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Endovascular repair of blunt traumatic thoracic aortic injuries (BTAI) is common at most trauma centres, with excellent results. However, little is known regarding which injuries do not require intervention. We reviewed the natural history of untreated patients with minimal aortic injury (MAI) at our centre. METHODS We conducted a retrospective database review to identify all patients with a BTAI between October 2008 and March 2010. The cohort comprised patients initially untreated because of the lesser degree of injury of an MAI. We reviewed initial and follow-up computed tomography (CT) scans and clinical information. RESULTS We identified 69 patients with a BTAI during the study period; 10 were initially untreated and were included in this study. Degree of injury included intimal flaps (n = 7, 70%), pseudoaneurysms with minimal hematoma (n = 2, 20%) and circumferential intimal tear (n = 1, 10%). Six (60%) patients were male, and the median age was 40 years. Duration of clinical follow-up ranged from 1 month to 6 years (median 2 mo) after discharge, whereas CT radiologic follow-up ranged from 1 week to 6 years (median 6 wk). Seven (70%) patients had complete resolution or stabilization of their MAI, 1 (10%) with circumferential intimal tear showed extension of the injury at 8 weeks postinjury and underwent successful repair, and 2 (20%) were lost to follow-up. CONCLUSION There appears to be a subset of patients with BTAI who require no surgical intervention. This includes those with limited intimal flaps, which often resolve. Radiologic surveillance is mandatory to ensure MAI resolution and identify any progression that might prompt repair.
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Affiliation(s)
| | - Daniel Abramowitz
- From the Division of Vascular Surgery, London Health Sciences Centre and the University of Western Ontario, London, Ont
| | - Jeremy R. Harris
- From the Division of Vascular Surgery, London Health Sciences Centre and the University of Western Ontario, London, Ont
| | - Guy DeRose
- From the Division of Vascular Surgery, London Health Sciences Centre and the University of Western Ontario, London, Ont
| | - Thomas L. Forbes
- From the Division of Vascular Surgery, London Health Sciences Centre and the University of Western Ontario, London, Ont
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Lamarche Y, Berger FH, Janusz MT. Reply to the Editor. J Thorac Cardiovasc Surg 2012. [DOI: 10.1016/j.jtcvs.2012.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Martí de Gracia M, Artigas Martín JM, Soto JA. Evaluation of thoracic vascular trauma with multidetector computed tomography. Semin Roentgenol 2012; 47:342-51. [PMID: 22929693 DOI: 10.1053/j.ro.2012.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Milagros Martí de Gracia
- Emergency Radiology Unit from Department of Radiology, La Paz University Hospital, Madrid, Spain.
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Coppi G, Tshomba Y, Psacharopulo D, Marone EM, Chiesa R. Aberrant right subclavian artery in blunt aortic injury: implication for treatment and review of the literature. Ann Vasc Surg 2012; 26:861.e1-6. [PMID: 22794343 DOI: 10.1016/j.avsg.2012.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 01/17/2012] [Indexed: 11/18/2022]
Abstract
Blunt aortic injury (BAI) involving an aberrant right subclavian artery (ARSA) is uncommon. The presence of an ARSA entails several treatment issues, in particular regarding the risk of perioperative posterior cerebral stroke. We report the case of a man with an ARSA who suffered from BAI. An initial conservative treatment with delayed open repair was chosen. A review of the published literature with discussion of the case is presented. The presence of an ARSA in patients with BAI can be considered a poor anatomy for endovascular repair, and suitable patients may benefit from delayed open repair.
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Affiliation(s)
- Giovanni Coppi
- Vascular Surgery-Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Milano, Italy.
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Descending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management. Curr Opin Crit Care 2012; 18:393-8. [PMID: 22710279 DOI: 10.1097/mcc.0b013e32835559a6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available. RECENT FINDINGS Endovascular treatment of thoracic aortic disease is expanding in applications and case complexity. SUMMARY With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.
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Minimal aortic injury after blunt trauma: selective nonoperative management is safe. ACTA ACUST UNITED AC 2012; 71:1519-23. [PMID: 22182862 DOI: 10.1097/ta.0b013e31823b9811] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increasing number of minimal aortic injuries (MAIs) are being identified with modern computed tomography (CT) imaging techniques. The optimal management and natural history of these injuries are unknown. We have adopted a policy of selective multidisciplinary nonoperative management of MAI. This study examines our experience with these patients from July 2004 to June 2009. METHODS Retrospective chart review of all blunt trauma patients who underwent chest CT angiography to evaluate for blunt aortic injury (BAI) was undertaken. All patients deemed to have a MAI were managed nonoperatively, and those with a severe aortic injury underwent repair. Data collected included age, mechanism of injury, Injury Severity Score, type and location of aortic injury, intensive care unit length of stay (LOS), overall LOS, ventilator days, disposition, and mortality. In addition, all BAIs were graded according to the Presley Trauma Center CT Grading System of Aortic Injury. RESULTS Forty-seven patients with BAI were identified. Thirty-two were classified as severe injuries, and 15 were considered MAI (32%). Nineteen underwent operative repair, 13 underwent endovascular stent graft repair, and 15 were managed nonoperatively. The average Injury Severity Score was 31 ± 10, and the average age was 44 ± 20 with no significant difference across treatment groups. There was no difference in overall or intensive care unit LOS. The nonoperative group had a shorter duration of ventilator days (1.1 vs. 4.28, p = 0.02). There were five deaths, none in the nonoperative group. None of these patients required subsequent intervention. All nonoperative patients had follow-up imaging at median of 4 days; on CT chest angiography, five injuries had resolved, eight had stable intimal flaps or pseudoaneurysm, and two had no detectable injury on subsequent aortogram. CONCLUSION Almost one-third of our BAI were safely managed nonoperatively. Patients with MAI should be considered for selective nonoperative management in a multidisciplinary approach with close radiographic follow-up. We recommend that patients with MAIs should be considered for selective nonoperative management.
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Demetriades D. Blunt thoracic aortic injuries: crossing the Rubicon. J Am Coll Surg 2012; 214:247-59. [PMID: 22265808 DOI: 10.1016/j.jamcollsurg.2011.11.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 11/28/2011] [Indexed: 11/24/2022]
Affiliation(s)
- Demetrios Demetriades
- Department of Surgery, Division of Acute Care Surgery, University of Southern California, LAC+USC Medical Center, Los Angeles, CA 90033-4525, USA.
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Lamarche Y, Berger FH, Nicolaou S, Bilawich AM, Louis L, Inacio JR, Janusz MT, Evans D. Vancouver simplified grading system with computed tomographic angiography for blunt aortic injury. J Thorac Cardiovasc Surg 2011; 144:347-54, 354.e1. [PMID: 22070925 DOI: 10.1016/j.jtcvs.2011.10.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 09/15/2011] [Accepted: 10/04/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Delineation of blunt aortic injury by computed tomographic angiography guides management of this potentially fatal injury. Two existing grading systems are problematic to apply and not linked to outcomes. A simplified computed tomographic angiography-based grading system, linked to clinical outcomes, was developed, and feasibility and reliability were evaluated. METHODS Retrospective review was performed of all blunt aortic injury cases presenting to a single provincial quaternary referral center designated for blunt aortic injury management between 2001 and 2009. Management, associated injuries, hospital survival, and cause of death were determined. Initial computed tomographic angiography was reviewed, and injuries were graded according to the new Vancouver simplified grading system by 2 study authors. Three additional trauma radiologists then graded the aortic injuries with the 2 existing systems and the simplified system. Interrater reliability was determined. RESULTS Forty-eight patients were identified. Two had minimal aortic injury (grade I), 7 had an intimal flap larger than 1 cm (grade II), 32 had traumatic pseudoaneurysm (grade III), 6 had active contrast extravasation (grade IV), and 1 could not be rated. Survivals were 100%, 90%, and 33% for grades I and II, III, and IV, respectively. Of grade III injuries, 14% were medically managed, 68% repaired endovascularly, and 18% repaired with open surgery. Interrater correlation was best with the simplified score, with only 0.5% of cases unable to be classified. CONCLUSIONS The Vancouver simplified blunt aortic injury grading system is easy to use and correlates with clinical outcomes. Prospective external validation is required.
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Affiliation(s)
- Yoan Lamarche
- Division of Cardiothoracic Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Reynolds TS, Donayre CE, Somma CG, Poggio WG, Kim KM, Nguyen T, White R. Endovascular management of blunt aortic injury with an associated aberrant right subclavian artery: a report of three cases. Ann Vasc Surg 2011; 25:979.e7-12. [PMID: 21764549 DOI: 10.1016/j.avsg.2011.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2010] [Revised: 04/25/2011] [Accepted: 05/12/2011] [Indexed: 11/17/2022]
Abstract
Traumatic rupture of the aorta in the rare setting of the aberrant right subclavian artery (ARSA) requires special consideration to prevent the occurrence of a devastating posterior cerebral circulation stroke. We present three cases managed by using an endovascular approach, with a discussion of important preoperative and operative issues. Three patients involved in motor vehicle collisions with multiple injuries were managed at two institutions. Computed tomography revealed transection of the aorta with incidental ARSA. All three cases were managed with a different approach. One patient did not undergo a preoperative bypass because imaging confirmed an adequate landing zone distal to the origin of the left subclavian artery. Two patients received preoperative right carotid-to-subclavian bypass for anticipated endograft coverage of both subclavian arteries to preserve single vertebral arterial flow. In one patient, an endovascular occlusion device was deployed in the ARSA before aortic endograft deployment. In the other, ARSA occlusion was performed 4 days later for a persistent type II endoleak. The patient who underwent bypass and preoperative ARSA occlusion suffered a fatal posterior circulation stroke shortly after surgery. The other two patients had no procedural complications and have not required any reinterventions at follow-up after 2 and 5 years. One patient is still undergoing rehabilitation after 5 years of follow-up for traumatic brain injury unrelated to the endograft repair. Although the incidence of ARSA is very low, preoperative imaging and assessment of cerebral blood flow are critical to prevent a perioperative stroke. Revascularization, if required to achieve a secure proximal landing zone, must be performed before endograft deployment. Bilateral subclavian revascularization is indicated if anomalies of the cerebral circulation are present.
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Affiliation(s)
- Tyler S Reynolds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
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Mosquera VX, Marini M, Lopez-Perez JM, Muñiz-Garcia J, Herrera JM, Cao I, Cuenca JJ. Role of conservative management in traumatic aortic injury: comparison of long-term results of conservative, surgical, and endovascular treatment. J Thorac Cardiovasc Surg 2011; 142:614-21. [PMID: 21269644 DOI: 10.1016/j.jtcvs.2010.10.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 09/29/2010] [Accepted: 10/24/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to compare early and long-term results in terms of survival and cardiovascular complications of patients with acute traumatic aortic injury who were conservatively managed with patients who underwent surgical or endovascular repair. METHODS From January 1980 to December 2009, 66 patients with acute traumatic aortic injury were divided into 3 groups according to treatment intention at admission: 37 patients in a conservative group, 22 patients in a surgical group, and 7 patients in an endovascular group. Groups were similar with regard to gender, age, Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. RESULTS In-hospital mortality was 21.6% in the conservative group, 22.7% in the surgical group, and 14.3% in the endovascular group (P = .57). In-hospital aortic-related complications occurred only in the conservative group. Median follow-up time was 75 months (range, 5-327 months). Conservative group survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years. Surgical group survival remained at 77.2% at 1, 5, and 10 years, whereas survival in the endovascular group was 85.7% at 1 and 5 years (P = .18). No patient in the surgical or endovascular group required reintervention because of aortic-related complications, whereas 37.9% of the conservative group had an aortic-related complication that required surgery or caused the patient's death during the follow-up period. Cumulative survival free from aortic-related complications in the conservative group was 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. Cox regression confirmed the initial type of aortic lesion (hazard ratio, 2.94; P = .002) and a Trauma Score-Injury Severity Score greater than 50% on admission (hazard ratio, 1.49; P = .042) as risk factors for the appearance of aortic-related complications. Two peaks in the complication rate of the conservative group were detected in the first week and between the first and third months after blunt thoracic trauma. CONCLUSIONS The advent of thoracic aortic endografting has enabled a revolution in the management of acute traumatic aortic injury in patients with multisystem trauma with a low in-hospital morbimortality. Nonoperative management may be only a therapeutic option with acceptable survival in carefully selected patients. The natural history of these patients has revealed a marked trend of late aortic-related complications developing, which may justify an endovascular repair even in some low-risk patients.
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Affiliation(s)
- Victor X Mosquera
- Department of Cardiac Surgery, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
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Kushimoto S, Shiraishi SI, Miyauchi M, Fukuda R, Masuno T, Yokota H. Visceral Ischemia Caused by Acute Aortic Dissection Following Blunt Aortic Injury: Report of a Case. J NIPPON MED SCH 2011; 78:110-5. [DOI: 10.1272/jnms.78.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
| | - Masato Miyauchi
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
| | - Reo Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
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