Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank

Chronic Post-Traumatic Aortic Isthmus Pseudoaneurysm After Conservative Management of Grade II Injury: Why Is Continuous Follow-Up Mandatory?

Background: Grade I-II blunt traumatic aortic injuries (BTAIs) are typically managed conservatively, but their long-term progression is poorly understood. Chronic pseudoaneurysms may develop years after the injury, often remaining asymptomatic and being incidentally diagnosed. Methods: Two cases of post-traumatic aortic pseudoaneurysms, detected 20 and 25 years following conservatively managed BTAIs, are reported. Additionally, a comprehensive review of all post-traumatic pseudoaneurysms reported in the MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) database between January 1984 and December 2024 was performed. Results: Both our patients underwent successful hybrid procedures, with no complications at the 1- and 4-year follow-ups. Our literature review identified 37 patients across 22 studies, with 32.4% presenting asymptomatically or incidentally diagnosed through routine imaging, between 1 month and 50 years after the initial trauma. In 37.8% of cases, the patients underwent open or endovascular repair. Conclusions: This case series and literature review emphasize the importance of long-term follow-up for patients with conservatively managed BTAIs, as chronic complications such as aortic pseudoaneurysms can arise decades later. Continuous surveillance is critical to ensure early detection and management.

Blunt thoracic aortic injury treated with thoracic endovascular aortic repair in hybrid emergency room: A case report

Background

Hybrid emergency rooms (ERs) allow computed tomography (CT) scanning, interventional radiology, and surgery all in the same suite. Severe trauma patients with blunt thoracic aortic injury (BTAI) require rapid diagnosis and treatment. Hybrid ERs allow the potential for clinicians to implement multiple therapeutic procedures, including thoracic endovascular aortic repair (TEVAR), for these types of conditions without the need to transport the patients.

Case presentation

A 35-year-old man sustained multiple injuries after a motor vehicle accident and was transferred to our hospital in shock status. CT revealed a grade IV BTAI rupturing into the thoracic cavity and pelvic fracture. Soon after preperitoneal pelvic packing and transcatheter arterial embolization for pelvic fracture, TEVAR was performed in the hybrid ER without transporting the patient. The patient was transferred to a rehabilitation hospital on postoperative day 41.

Conclusion

Hybrid ERs enable clinicians to perform all life-saving procedures, including stent grafting for traumatic patients with aortic injuries, in the same place.

Blunt Traumatic Aortic Injury Treated with Endovascular Aortic Repair: Does Age Influence the Outcome?

Background: Blunt traumatic aortic injury (BTAI) is the second most common cause of death following blunt trauma, and it can affect people of all ages. The aim of this study was to evaluate age-related differences in outcomes among patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI. Methods: All patients treated with TEVAR for BTAI at a tertiary care center in Europe between 2005 and 2023 were included in this study. All clinical and imaging data were collected and analyzed retrospectively. Results: A total of 70 patients with a median age of 43 years were included, and 89% were male. Older patients had significantly higher American Society of Anesthesiologists (ASA) physical status classification scores (p < 0.001) compared to younger patients. All age groups (<18, 18-40, 41-65, and >65) exhibited low to borderline low initial hemoglobin levels with a further decline over time (p = 0.063, p < 0.001, p < 0.001, and p = 0.018, respectively). Age groups were comparable regarding injury mechanism, Injury Severity Score (ISS), concomitant injuries and postoperative complications. The age-independent ISS showed a moderate to strong correlation to the length of intensive care unit stay (r = 0.594, p < 0.001). Total in-hospital mortality was 6% and none was from aortic-related complications. There was a generally high rate of loss of follow-up (59%). Conclusions: Although older patients presented worse ASA scores in comparison to younger patients, no significant differences regarding postoperative morbidity/mortality were noted. These findings imply that patient age and preinjury physical status might not substantially influence outcomes when treating BTAI with TEVAR.

Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus.

CONCLUSION

The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation.

Predicting the future caretakers of traumatic vascular injury management via operative exposure among surgical trainees

BACKGROUND

The management of vascular trauma requires specialized training and expertise. Although traumatic vascular injury is treated currently by both vascular and trauma surgeons in modern practice, it remains unclear who will inherit the role of managing vascular trauma in the coming decades. In this study, we examined disparities in operative experience in vascular trauma among surgical trainees across different surgical specialties.

METHODS

Accreditation Council for Graduate Medical Education national operative log reports were collected for graduating vascular surgery residents (VSRs), vascular surgery fellows (VSFs), and general surgery residents (GSRs) from 2012 to 2022. Total operative volume for traumatic vascular injury was examined, as were the five major contributing operative domains (neck, thoracic, abdominal, peripheral, and fasciotomy).

RESULTS

A total of 22,052 GSRs, 334 VSRs, and 1672 VSFs graduated over the 10-year study period. VSR had the highest vascular trauma case volume (24.9 ± 3.9 cases/5 years), followed by VSF (22.1 ± 1.5 cases/2 years) then GSR (2.4 ± 0.3 cases/5 years; P < .001). Thoracic vessel exploration/repair (0.7 cases vs 0.6 cases vs 0.0 cases), abdominal vessel exploration/repair (1.0 cases vs 0.9 cases vs 0.0 cases), neck vessel exploration/repair (4.0 cases vs 3.4 cases vs 0.2 cases), peripheral vessel exploration/repair (12.1 cases vs 9.5 cases vs 1.1 cases), and lower extremity fasciotomy for trauma (7.2 cases vs 7.6 cases vs 1.1 cases) were most frequent among the VSR and VSF groups (P < .001 each). On linear regression analysis, both VSF (+0.5 cases/y; R2 = 0.81; P < .001) and GSR (+0.1 cases/y; R2 = 0.75; P = .001) groups experienced a growth in vascular trauma volume. Contrariwise, vascular trauma volume did not change among graduating VSRs (R2 = 0.13; P = .31).

CONCLUSIONS

Dedicated vascular surgical training provides the highest operative exposure to civilian vascular trauma in the United States.

Using machine learning to predict outcomes of patients with blunt traumatic aortic injuries

BACKGROUND

The optimal management of blunt thoracic aortic injury (BTAI) remains controversial, with experienced centers offering therapy ranging from medical management to TEVAR. We investigated the utility of a machine learning (ML) algorithm to develop a prognostic model of risk factors on mortality in patients with BTAI.

METHODS

The Aortic Trauma Foundation registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. A STREAMLINE (A Simple, Transparent, End-To-End Automated Machine Learning Pipeline Facilitating Data Analysis and Algorithm Comparison) model as well as logistic regression (LR) analysis with imputation using chained equations was developed and compared.

RESULTS

From a total of 1018 patients in the registry, 702 patients were included in the final analysis. Of the 258 (37%) patients who were medically managed, 44 (17%) died during admission, 14 (5.4%) of which were aortic related deaths. Four hundred forty-four (63%) patients underwent TEVAR and 343 of which underwent TEVAR within 24 hours of admission. Among TEVAR patients, 39 (8.8%) patients died and 7 (1.6%) had aortic related deaths ( Table 1 ). Comparison of the STREAMLINE and LR model showed no significant difference in ROC curves and high AUCs of 0.869 (95% confidence interval, 0.813-0.925) and 0.840 (95% confidence interval, 0.779-0.900) respectively in predicting in-hospital mortality. Unexpectedly, however, the variables prioritized in each model differed between models. The top 3 variables identified from the LR model were similar to that from existing literature. The STREAMLINE model, however, prioritized location of the injury along the lesser curve, age and aortic injury grade.

CONCLUSION

Machine learning provides insight on prioritization of variables not typically identified in standard multivariable logistic regression. Further investigation and validation in other aortic injury cohorts are needed to delineate the utility of ML models.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma?

PURPOSE

Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization.

MATERIALS AND METHODS

From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups.

RESULTS

Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001).

CONCLUSION

An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI.

CLINICAL IMPACT

More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.

Feasibility of non-operative management for patients sustained blunt splenic traumas with concomitant aortic injuries

PURPOSE

This study aimed to elucidate the treatment approach for blunt splenic injuries concurrently involving the aorta. We hypothesized that non-operative management failure rates would be higher in such cases, necessitating increased hemorrhage control surgeries.

METHODS

Data from the Trauma Quality Improvement Program spanning 2017 to 2019 were utilized. All patients with blunt splenic trauma were considered for inclusion. We conducted comparisons between blunt splenic trauma patients with and without thoracic or abdominal aortic injuries to identify any potential disparities in treatment.

RESULTS

Among the 32,051 patients with blunt splenic injuries during the study period, 752 (2.3%) sustained concurrent aortic injuries. Following 2:1 propensity score matching, it was determined that the presence of aortic injuries did not significantly affect the utilization of splenic transarterial angioembolization (TAE) (7.2% vs. 8.7%, p = 0.243) or the necessity for splenectomy or splenorrhaphy (15.3% vs. 15.7%, p  = 0.853). Moreover, aortic injuries were not a significant factor contributing to TAE failure, regardless of the location or severity of the injury. Patients with simultaneous splenic and aortic injuries required more red blood cell transfusion within first 4 hours (0 ml [0, 900] vs. 0 ml [0, 650], p  = 0.001) and exhibited a higher mortality rate (10.6% vs. 7.9%, p = 0.038).

CONCLUSION

This study demonstrated that patients with concurrent aortic and splenic injuries presented with more severe conditions, higher mortality rates, and extended hospital stays. The presence of aortic injuries did not substantially influence the utilization of TAE or the necessity for splenectomy or splenorrhaphy. Patients of this type can be managed in accordance with current treatment guidelines. Nonetheless, given their less favorable prognosis, they necessitate prompt and proactive intervention.

Development and Validation of a Risk Prediction Tool for In-hospital Mortality After Thoracic Endovascular Repair in Patients with Blunt Thoracic Aortic Injury Using the Aortic Trauma Foundation Registry

BACKGROUND

The objective of our present effort was to use an international blunt thoracic aortic injury (BTAI) registry to create a prediction model identifying important preoperative and intraoperative factors associated with postoperative mortality, and to develop and validate a simple risk prediction tool that could assist with patient selection and risk stratification in this patient population.

METHODS

For the purpose of the present study, all patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI and registered in the Aortic Trauma Foundation (ATF) database from January 2016 as of June 2022 were identified. Patients undergoing medical management or open repair were excluded. The primary outcome was binary in-hospital all-cause mortality. Two predictive models were generated: a preoperative model (i.e. only including variables before TEVAR or intention-to-treat) and a full model (i.e. also including variables after TEVAR or per-protocol).

RESULTS

Out of a total of 944 cases included in the ATF registry until June 2022, 448 underwent TEVAR and were included in the study population. TEVAR for BTAI was associated with an 8.5% in-hospital all-cause mortality in the ATF dataset. These study subjects were subsequently divided using 3:1 random sampling in a derivation cohort (336; 75.0%) and a validation cohort (112; 25.0%). The median age was 38 years, and the majority of patients were male (350; 78%). A total of 38 variables were included in the final analysis. Of these, 17 variables were considered in the preoperative model, 9 variables were integrated in the full model, and 12 variables were excluded owing to either extremely low variance or strong correlation with other variables. The calibration graphs showed how both models from the ATF dataset tended to underestimate risk, mainly in intermediate-risk cases. The discriminative capacity was moderate in all models; the best performing model was the full model from the ATF dataset, as evident from both the Receiver Operating Characteristic curve (Area Under the Curve 0.84; 95% CI 0.74-0.91) and from the density graph.

CONCLUSIONS

In this study, we developed and validated a contemporary risk prediction model, which incorporates several preoperative and postoperative variables and is strongly predictive of early mortality. While this model can reasonably predict in-hospital all-cause mortality, thereby assisting physicians with risk-stratification as well as inform patients and their caregivers, its intrinsic limitations must be taken into account and it should only be considered an adjunctive tool that may complement clinical judgment and shared decision-making.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury

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.

Management of Concurrent Pediatric Blunt Aortic and Traumatic Brain Injury

This is the case of a pediatric blunt trauma patient who presented with a concurrent blunt traumatic aortic and severe brain injury. We describe successful simultaneous management of the aortic and brain injury with delayed endovascular repair of the aorta. This report details the importance of multidisciplinary discussion in definitive management of children with these concurrent injuries and the endovascular technical considerations in children.

Rule of four: an anatomic and value-based approach to stent-graft inventory for blunt thoracic aortic injury

PURPOSE

As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory.

METHODS

CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr 2010-Dec 2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients.

RESULTS

Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2 years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series.

CONCLUSIONS

Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance.

Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

Effect of the Profit and Teaching Status of Hospitals on the Patterns and Outcomes of Abdominal Aorta and Inferior Vena Cava Injuries after Severe Abdominal Trauma

Background

The inferior vena cava (IVC) and the abdominal aorta (AA) are two important blood vessels located in the abdomen. The outcomes of such injuries rely heavily on the experience, expertise, and resources available at the hospital where the patient is treated. However, our current understanding of the potential impact of the hospital profit and teaching status on surgical outcomes in the context of traumatic injuries to the IVC and AA remains limited, making it important to investigate the potential association between these hospital characteristics and patient outcomes to enhance the quality of care and optimize treatment strategies.

Objective

This study aimed to compare demographics, trauma characteristics, and outcomes between nonprofit status (NPSH) and for-profit hospital status (FPSH), as well as among community hospitals (CHs), nonteaching hospitals (NTHs), and university hospitals (UHs), in patients with severe abdominal trauma and abdominal aorta injury (AAI), inferior vena cava injury (IVCI), and both (AAI + IVCI).

Methods

Demographics, trauma, and outcome measures associated with AAI, IVCI, and AAI + IVCI were compared between the different profit and teaching status groups using NTDB. Multivariate regression was used to identify independent factors associated with death under care (DUC).

Results

In the 2017 NTDB-RDS, 1,479 patients met the inclusion criteria, resulting in an overall incidence of 0.17% for AAI, IVCI, and AAI + IVCI after severe abdominal trauma. More patients died under care in the FPSH group than in the NPSH group (nonprofit vs. for-profit: 60.3% vs. 47.2%; P < 0.001). The results indicated that FPSH independently affected DUC. NTH had no significant effect on DUC; although the in-hospital complication rate varied with NTH, no independent association was observed.

Conclusions

The study findings demonstrated that in patients with severe abdominal trauma, including injuries to AAI, IVCI, or both (AAI + IVCI), the profit status of hospitals, rather than the teaching status, had a substantial influence on DUC. Future studies should examine differences in the volume of cases and levels of trauma centers to better understand how to improve patient outcomes in FPSH.

Endovascular treatment of a traumatic thoracic pseudo-aneurysm in a pediatric patient: a case report with review of literature

Blunt aortic injury (BAI) as a result of thoracic trauma is a rare entity in the adult and pediatric population. The endovascular approach has been the preferred method of management over operative repair in adults. However, data on pediatrics is limited to case reports and case series with no long-term follow-up. There are no current guidelines for management in the pediatric population. We are reporting a successful repair of a traumatic thoracic aortic aneurysm in a 13 year old boy with covered stents, with a review of relevant literature.

Is Chest X-Ray a Reliable Screening Tool for Blunt Thoracic Aortic Injury? Results from the American Association for the Surgery of Trauma/Aortic Trauma Foundation Prospective Blunt Thoracic Aortic Injury Registry

BACKGROUND

Traditional teaching continues to espouse the value of initial trauma chest x-ray (CXR) as a screening tool for blunt thoracic aortic injury (BTAI). The ability of this modality to yield findings that reliably correlate with grade of injury and need for subsequent treatment, however, requires additional multicenter prospective examination. We hypothesized that CXR is not a reliable screening tool, even at the highest grades of BTAI.

STUDY DESIGN

The Aortic Trauma Foundation/American Association for the Surgery of Trauma prospective BTAI registry was used to correlate initial CXR findings to the Society for Vascular Surgery injury grade identified with computed tomographic angiography.

RESULTS

We analyzed 708 confirmed BTAI injuries with recorded CXR findings and subsequent computed tomographic angiography injury characterization from February 2015 to August 2021. The presence of any of the classic CXR findings was observed in only 57.6% (408 of 708) of injuries, with increasing presence correlating with advanced Society for Vascular Surgery BTAI grade (39.1% [75 of 192] of grade 1; 55.6% [50 of 90] of grade 2; 65.2% [227 of 348] of grade 3; and 71.8% [56 of 78] of grade 4). The most consistent single finding identified was widened mediastinum, but this was only present in 27.7% of all confirmed BTAIs and only 47.4% of G4 injuries (7.8%% of grade 1, 23.3%, of grade 2, 35.3% of grade 3, and 47.4% of grade 4).

CONCLUSIONS

CXR is not a reliable screening tool for the detection of BTAI, even at the highest grades of injury. Further investigations of specific high-risk criteria for screening that incorporate imaging, mechanism, and physiologic findings are warranted.

Nationwide Analysis of Penetrating Thoracic Aortic Injury: Injury Patterns, Management, and Outcomes

INTRODUCTION

Penetrating thoracic aortic injuries (PTAI) represent a rare form of thoracic trauma. Unlike blunt thoracic aortic injuries (BTAI), only scarce data, included in small case series, are currently available for PTAI. The purpose of this study was to describe injury patterns, surgical management, and outcomes of patients with PTAI and compare to those with BTAI.

MATERIALS AND METHODS

A 9-y retrospective cohort study (2007-2015) was conducted using the National Trauma Data Bank. Patient demographics, injury profile, procedures performed, and patient outcomes were compared between the PTAI and BTAI group.

RESULTS

A total of 2714 patients with PTAI and 14,037 patients with BTAI were identified. Compared to BTAI, PTAI patients were younger (28 versus 42 y, P < 0.001), more often male (89.1% versus 71.7%, P < 0.001), and more likely to arrive without signs of life (27.6% versus 7.5%, P < 0.001). PTAI patients had less associated injuries, overall, compared to those with BTAI; however, were more likely to have injuries to the esophagus, diaphragm, and heart. Patients with PTAI were less likely to undergo endovascular (5.8% versus 30.5%, P < 0.001) or open surgical repair (3.0% versus 4.2%, P < 0.001) compared to BTAI. While the large majority of PTAI patients expired before their hospital arrival or in the emergency department, the in-hospital mortality rate among those who survivedemergency department stay was 43.1%.

CONCLUSIONS

Most patients with PTAI present to the hospital without any signs of life, and their overall mortality rate is extremely high. Only a small portion of PTAI patients who survived the initial resuscitation period underwent surgical interventions for thoracic aortic injuries. Further studies are still warranted to clarify the indications and types of surgical interventions for PTAI.

Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma

BACKGROUND

Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C.

METHODS

The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization.

RESULTS

Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001).

CONCLUSION

While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Blunt traumatic aortic injury in the elderly population

OBJECTIVE

Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database.

METHODS

Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management.

RESULTS

During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group.

CONCLUSIONS

This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.

Minimal Aortic Injury Detected on Computed Tomography Angiography during Initial Trauma Imaging: Single Academic Level 1 Trauma Center Experience

BACKGROUND

 Minimal aortic injury (MAI), a subtype of acute traumatic aortic injury, is being increasingly recognized with better imaging techniques. Given conservative management, the role of follow-up imaging albeit important yet has to be defined.

METHODS

 All trauma chest computed tomography angiographies (CTAs) at our center between January 2012 and January 2019 were retrospectively reviewed for presence of MAI. MAIs were generally reimaged at 24 to 72 hours and then at a 7- and 30-day interval. Follow-up CTAs were reviewed for stability, progression, or resolution of MAI, along with assessment of injury severity scores (ISS) and concomitant injuries, respectively.

RESULTS

 A total of 17,569 chest CTAs were performed over this period. Incidence of MAI on the initial chest CTA was 113 (0.65%), with 105 patients receiving follow-up CTAs. The first, second, third, and fourth follow-up CTAs were performed at a median of 2, 10, 28, and 261 days, respectively. Forty five (42.9%), 22 (21%), 5 (4.8%), and 1 (1%) of the MAIs were resolved by first, second, third, and fourth follow-up CTAs. Altogether, 21 patients showed stability (mean ISS of 16.6), and 11 demonstrated improvement (mean ISS 25.8) of MAIs. Eight patients had no follow-up CTA (mean ISS 21). No progression to higher-grade injury was observed. Advancing age decreased the odds of MAI resolution on follow-up. A possible trend (p-value 0.22) between increasing ISS and time to resolution of MAIs was noted.

CONCLUSION

 In our series of acute traumatic MAIs diagnosed on CTA imaging, there was no progression of injuries with conservative management, questioning the necessity of sequential follow-up imaging.

Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Repair Is Rarely Indicated

BACKGROUND

Thoracic endovascular repair has become the standard treatment for blunt thoracic aortic injury (BTAI). Occlusion of the left subclavian artery (LSA) is generally required for an adequate landing zone (ALZ). We propose that coverage of the LSA is not necessary for BTAI even with a short landing zone (SLZ).

METHODS

Retrospective review of BTAI patients, who were treated from January 2008 to December 2020, was analyzed. BTAI was categorized into 2 cohorts, SLZ <20 mm and ALZ >20 mm. Demographic data, trauma scores, grade of BTAI, procedure-related data, and clinical outcomes were analyzed. t-Test and chi-squared tests were used for statistical analysis.

RESULTS

Thoracic endovascular repair was performed in 59 BTAI patients (mean age of 38.9 ± 14 years, mean Injury Severity Score of 40.4 ± 9.3). Two cohorts were identified: 49 patients had an SLZ, and 10 patients had an ALZ (14 ± 3.1 mm vs. 25 ± 4.1 mm, P = 0.03). The procedures were performed successfully with 59 patients (86.4%) deploying in zone 3. In-hospital mortality (SLZ group: 4.1% vs. ALZ group: 0, P = 0.318), endoleak (SLZ group: 4.1% vs. ALZ group: 20%, P = 0.45), stroke (SLZ group: 0 vs. ALZ group: 0, P = 1), spinal cord ischemia (SLZ group: 2% vs. ALZ group: 0, P = 1), left arm ischemia (SLZ group: 0 vs. ALZ group: 0, P =1), and reintervention rate (SLZ group: 0 vs. ALZ group: 0, P = 1) were not statistically different between cohorts.

CONCLUSIONS

BTAI repair with an SLZ can be treated successfully without covering the LSA, analyzing technical success and in-hospital complications. Mid- and long-term data are necessary to confirm the durability of this technique.

Close surveillance imaging is unnecessary for patients with grade I blunt thoracic aortic injury

BACKGROUND

No evidence-based recommendations exist for imaging surveillance of grade I blunt thoracic aortic injuries (BTAI). We aimed to evaluate the natural history of these injuries to provide guidance for follow-up imaging.

METHODS

Patients that presented to our trauma center from 2008 to 2021 with grade I BTAI were retrospectively evaluated. CT angiography images were assessed for initial injury grade and subsequent stability, improvement, worsening, or resolution.

RESULTS

Of 83 patients who had grade I injuries and repeat imaging, 57.8% had complete resolution, 20.5% had improvement, and 18.1% had stability of their injury. Only seven patients (8.4%) demonstrated worsening of their injury. Six patients had eventual resolution and one underwent endovascular repair that would not have been performed under current practice patterns.

CONCLUSIONS

Since grade I injuries do not worsen to require later surgical intervention, early surveillance imaging is not necessary and further imaging may not be necessary at all.

Outcomes of Operative and Non-Operative Management in Blunt Thoracic Aortic Injury

OBJECTIVES

Although current guidelines for management of blunt traumatic aortic injury (BTAI) recommend intervention for grade 2 injury or higher, there is a national trend of aggressive endovascular treatment of low-grade BTAI. Little is known about the natural history of grade 1-2 injuries treated non-operatively. We hypothesized that most of these low-grade injuries remain stable with non-operative management.

METHODS

A review of blunt thoracic aortic injuries (BTAI) at a large referral Level 1 trauma center from 2004-2020 was performed. Injuries were graded on a standard 1-4 scale. Outcomes of both non-operative and TEVAR management strategies were compared, including post-trauma morbidity, mortality, re-intervention, and lesion stability.

RESULTS

176 patients with BTAI, sufficient imaging, and follow-up were identified during the time period. 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with grade 4 injury. Of those 176 patients, 112 underwent thoracic endovascular aortic repair (TEVAR) and 64 were managed non-operatively. Most (90.2%) undergoing TEVAR had grade 3 injuries. Non-operative management was performed for 97.2% of grade 1 injuries and 62.5% of grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). Post-trauma morbidity within 30 days (stroke [3.6 vs. 3.1%], MI/arrhythmia [8.9 vs. 1.6%], respiratory failure [31.2 vs. 28.1%], acute kidney injury [9.8 vs. 12.5%], UTI [2.7 vs. 4.8%], GI bleeding [3.6 vs. 0.0%], PE [10.9 vs. 4.5%]) and 1-year mortality after discharge [1.8 vs. 3.1%] were comparable between operative and non-operative groups. Median [IQR] follow up was 1501 [475.6, 2804] days in the TEVAR group and 1170.5 [317, 2173] days in the non-operative group. There was no progression of lesions in patients with low-grade (1-2) injuries managed non-operatively. Resolution of grade 1-2 injury was seen in 20% of patients at 30 days, improving to 44% during long-term follow up. Fourteen patients with grade 3 injuries (12.2% of grade 3 injuries in this series) were also observed and did not require future intervention. These patients generally had smaller pseudoaneurysms with minimal periaortic hematoma. None progressed or resulted in rupture on follow-up (454.5 [81, 1199] days CT scan follow up).

CONCLUSIONS

Non-operative management of low-grade BTAI does not result in long-term aortic complications or need for reintervention. Those grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma may be safely observed if they can be appropriately followed, and that indications for treatment of select grade 3 injuries merits further consideration.

Blunt Traumatic Aortic Injury Management, a French TraumaBase Analytic Cohort

OBJECTIVE

Blunt traumatic aortic injury (BTAI) in severe trauma patients is rare but potentially lethal. The aim of this work was to perform a current epidemiological analysis of the clinical and surgical management of these patients in a European country.

METHODS

This was a multicentre, retrospective study using prospectively collected data from the French National Trauma Registry and the National Uniform Hospital Discharge Database from 10 trauma centres in France. The primary endpoint was the prevalence of BTAI. The secondary endpoints focused chronologically on injury characteristics, management, and patient outcomes.

RESULTS

209 patients were included with a mean age of 43 ± 19 years and 168 (80%) were men. The calculated prevalence of BTAI at hospital admission was 1% (162/15 094) (BTAI admissions/all trauma). The time to diagnosis increased with the severity of aortic injury and the clinical severity of the patients (grade 1: 94 [74, 143] minutes to grade 4: 154 [112, 202] minutes, p = .020). This delay seemed to be associated with the intensity of the required resuscitation. Sixty seven patients (32%) received no surgical treatment. Among those treated, 130 (92%) received endovascular treatment, 14 (10%) open surgery (two were combined), and 123 (85%) were treated within the first 24 hours. Overall mortality was 20% and the attributed cause of death was haemorrhagic shock (69%). Mortality was increased according to aortic injury severity, from 6% for grade 1 to 65% for grade 4 (p < .001). Twenty-six (18.3%) patients treated by endovascular aortic repair had complications.

CONCLUSION

BTAI prevalence at hospital admission was low but occurred in severe high velocity trauma patients and in those with a high clinical suspicion of severe haemorrhage. The association of shock with high grade aortic injury and increasing time to diagnosis suggests a need to optimise early resuscitation to minimise the time to treatment. Endovascular treatment has been established as the reference treatment, accounting for more than 90% of interventional treatment options for BTAI.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy

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.

Observational management of Grade II or higher blunt traumatic thoracic aortic injury: 15 years of experience at a single suburban institution

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.

Atypical presentation of isolated traumatic ascending aortic dissection with cardiac tamponade

Blunt traumatic aortic injury is a rare but life-threatening condition, usually following high-energy trauma. We present the case of a 79-year-old man who was transferred to a hospital complaining of nausea after being struck on the chest. Computed tomography led to diagnosis of ascending aortic dissection with cardiac tamponade. Emergent ascending aortic replacement was performed successfully and he was discharged home on postoperative day 24 without any complications. The key to early diagnosis of blunt traumatic aortic injury is careful and detailed history-taking. If trauma patients complain of unexplained symptoms, the threshold for conducting computed tomography should be lowered to avoid misdiagnosis or therapeutic delay.

Successful application of angioembolization and thoracic endovascular aortic repair (TEVAR) in a retrograde type-A acute aortic dissection with polytrauma

A 53-year-old man underwent thoracic endovascular aortic repair for persistent false lumen perfusion and limb salvage because of type A aortic dissection, severe lower-limb ischemia, and bleeding (mediastinal hematoma, bilateral lung contusion, liver injury, and splenic injury) caused by blunt trauma. We embolized the left supreme intercostal artery to control active mediastinal hemorrhage. Acute hemorrhage and leg ischemia were well controlled; however, residual blood flow in the false lumen persisted. We performed a Zone 2 thoracic endovascular aortic repair and discharged the patient on day 67. Thoracic endovascular aortic repair is a practical option for treating traumatic type A dissection.

Aortic Impingement in Displaced Traumatic Spine Fracture with Complete Spinal Cord Transection: A Case Report

Aortic impingement associated with traumatic thoracic spinal fractures is a rare and potentially lethal complication that creates management challenges in an already complex clinical problem. Traumatic aortic injury is one of the leading causes of death in blunt trauma. Magerl divided thoracic and lumbar fractures into 3 categories; the primary focus of this report, type C fractures, describes rotational injury and is one of the less common types, especially associated with aortic impingement as such. In this case, a young man was admitted following a near-fatal fall resulting in blunt force trauma to the midthoracic region. Emergency CT revealed a type C complete transection at the level of T11 and a grade I aortic injury. Definitive fixation of the spinal injury was delayed in favor of preventing further vascular injury by prioritizing the securing of hemodynamic stability. In traumatic thoracolumbar injuries, blunt traumatic aortic injury is often managed conservatively. However, blunt thoracic aortic injury is one of the leading causes of death from trauma, and each case requires its own case-by-case multidisciplinary management. In this occasion, management of the vascular insult was paramount to ensuring patient survival and favorable outcome.

Retrospective study of thoracic endovascular aortic repair as a first-line treatment for traumatic blunt thoracic aortic injury

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.

Early Clinical Diagnosis and Treatment of Traumatic Aortic Injury Caused by Thoracic and Abdominal Injuries: A Series of Four Cases with Literature Review

Aortic injury, particularly traumatic aortic dissection caused by thoracic and abdominal injuries, is extremely rare. The diagnosis rate of blunt aortic injury caused by chest and abdominal injuries is often low, and its clinical manifestations are atypical. Once missed or misdiagnosed, the consequences are serious. Early diagnosis of traumatic aortic injury in complex thoracic and abdominal injuries is a key factor in reducing the mortality of trauma patients. Among all trauma patients treated in our department from December 2018 to December 2020, we diagnosed four cases of aortic injury, including three cases of aortic dissection and one case of intramural hematoma. Successful surgical treatment and clinical outcome were achieved in all four patients. We found that early diagnosis and surgical treatment can help to reduce the mortality of patients with traumatic aortic injury and improve the prognosis.

Where Does Interventional Radiology Fit in with Trauma Management Algorithm?

Trauma is a major cause of death in the United States, particularly in the younger population. Many traumatic deaths, as well as major morbidity, occur secondary to uncontrolled hemorrhage and eventual exsanguination. Interventional radiology plays a major role in treating these patients, and interventional techniques have evolved to the point where they are an integral part of treatment in these critically ill patients. This article reviews the role of interventional radiology in the treatment algorithms for traumatic injury sponsored by major societies and associations.

Thoracic Trauma: Aortic Injuries

Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.

Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience

OBJECTIVE

 In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center.

METHODS

 Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls.

RESULTS

 A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16-80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4-115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention.

CONCLUSION

 Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.

The Current Role of Interventional Radiology in the Management of Acute Trauma Patient

Trauma is one of the most common causes of death, particularly in younger individuals. The development of specialized trauma centers, trauma-specific intensive care units, and trauma-focused medical subspecialties has led to the formation of comprehensive multidisciplinary teams and an ever-growing body of research and innovation. The field of interventional radiology provides a unique set of minimally invasive, endovascular techniques that has largely changed the way that many trauma patients are managed. This article discusses the role of interventional radiology in the care of this complex patient population, and in particular how the specialty fits into the overall team management of these patients.

Do patients with minimal blunt thoracic aortic injury require thoracic endovascular repair?

INTRODUCTION

The optimal management of minimal blunt thoracic aortic injuries (BTAIs) remains controversial, with experienced centers using therapy ranging from medical management (MM) to thoracic endovascular aortic repair (TEVAR).

METHODS

The Aortic Trauma Foundation registry was used to examine demographics, injury characteristics, management, and outcomes of patients with BTAI.

RESULTS

Two hundred ninety-six patients from 28 international centers were analyzed (mean age, 44.5 years [SD, 18 years]; 76% [225/296] male; mean Injury Severity Score, 34 [SD, 14]). Blunt thoracic aortic injury was classified as Grade I, 22.6% (67/296); Grade II, 17.6% (52/296); Grade III, 47.3% (140/296); and Grade IV, 12.5% (37/296). Overall aortic-related mortality (ARM) was 4.7% (14/296). Among all deaths, 33% (14/42) were ARM. Open repair was required for only 2%, with most undergoing TEVAR (58.4%) or MM (28.0%). Thoracic endovascular repair complications occurred in 3.4% (6/173), most commonly Type 1 endoleak (2.3%; 4/173). Among patients with minimal aortic injury (Grades I and II), 59.7% (71/119) received MM, while 40.3% (48/119) underwent TEVAR. Two patients initially managed with MM required subsequent TEVAR for injury progression during initial hospital stay. No significant difference in ARM between MM and TEVAR was noted for Grades I and II injuries.

CONCLUSION

A third of the trauma victims with BTAI succumb to ARM. Thoracic endovascular repair has replaced open repair but remains equivalent in outcomes to MM for minimal injuries. These data support MM of patients with minimal aortic injury.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

A Rapid Diagnosis and Treatment of a Traumatic Aortic Transection: A Case of Survival to the ICU

We present the case of a young man with traumatic aortic dissection secondary to a motor vehicle collision. While the differential diagnosis for traumatic injury after a motor vehicle collision can include commonly studied and trained for cases, such as pneumo/hemothorax, pulmonary contusion, splenic laceration, and pelvic fractures, for example, one of the more deadly and hence rare presentations of motor vehicle trauma is aortic transection. The fact that the diagnostic studies included as part of the initial Advanced Trauma Life Support^® (ATLS^®) trauma survey are not well equipped to diagnose such an injury is also a deadly factor. In this case review, we explore factors affecting the timely diagnosis, management, and outcomes of traumatic aortic injury. Prompt diagnosis is imperative in order to save a patient's life.

Management of Moderate Blunt Thoracic Aortic Injuries in Patients with Intracranial Hemorrhage

BACKGROUND

Blunt thoracic aortic injuries (BTAIs) are the second most common cause of death due to blunt-force trauma in the United States. Patients with minimal injuries do not typically require surgical repair, whereas patients with severe injuries are treated emergently. Moderate aortic injuries are repaired in a semielective fashion, but the optimal management of patients with moderate BTAI with associated intracranial hemorrhage (ICH) is unknown. We sought to analyze the management and outcomes of patients presenting with concomitant moderate BTAI and ICH.

METHODS

Consecutive patients who received a thoracic endovascular aortic repair (TEVAR) at our institution for treatment of moderate BTAI between January 2014 and December 2017 were retrospectively reviewed as part of an institutional review board-approved protocol. Patients were classified by our BTAI classification into "minimal", "moderate", or "severe". ICH was identified on computed tomography scan and its severity determined by the neurosurgical team. Outcome measures included surgical timing and surgical outcomes.

RESULTS

Fifty-two patients had a moderate BTAI and underwent TEVAR, 20 (38 %) of whom presented with ICH. Median time from admission to surgery was 58.5 hr for patients with ICH and 26.5 hr for non-ICH patients. Intraoperative heparin was administered in all patients without ICH and in 19 of 20 (95%) patients with ICH after the ICH met criteria for stability. Protamine reversal was utilized in 80% of patients with ICH and 75% of non-ICH patients. No patient developed ischemic stroke or spinal cord ischemia. Worsening ICH was seen in only one patient, who also received heparin infusion for pulmonary embolus 24 hr before TEVAR. There were no aortic-related mortalities in either group. Thirty-day all-cause mortality was 5% for patients with ICH and 3% for non-ICH patients.

CONCLUSIONS

Patients with moderate BTAI and stable ICH are not at increased risk of TEVAR-related complications. Administration of intraoperative heparin during TEVAR appears to be safe and does not worsen ICH.

Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) is an effective treatment of blunt thoracic aortic injury (BTAI). However, the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications.

METHODS

The Vascular Quality Initiative registry was queried from 2013 to 2019 to identify patients who had undergone TEVAR for BTAI with or without the administration of intraoperative heparin. Univariate analyses were performed with the Student t test, Fisher exact test, or χ² test, as appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality.

RESULTS

A total of 655 patients were included, of whom most had presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) of ≥15 (70.2% vs 90.5%; P < .0001) or major head or neck injury (39.6% vs 62.9%; P < .0001). Patients receiving heparin also had a lower incidence of inpatient death (5.1% vs 12.9%; P < .01). Across all injury grades, heparin use was not associated with the need for intraoperative transfusion or postoperative transfusion or the development of hematoma. In patients with grade III BTAI, the nonuse of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%; P < .05). On multivariable logistic regression analysis for inpatient mortality, intraoperative heparin use (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P < .05) and female gender (OR, 0.11; 95% CI, 0.11-0.86; P < .05) were associated with better survival, even after controlling for head and neck trauma and injury grade. In contrast, increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), postoperative transfusion (OR, 1.06; 95% CI, 1.02-1.11; P < .01), higher ISS (OR, 1.04; 95% CI, 1.01-1.07; P < .05), postoperative dysrhythmia (OR, 4.48; 95% CI, 1.10-18.18; P < .05), and postoperative stroke or transient ischemic attack (OR, 5.54; 95% CI, 1.11-27.67; P < .05) were associated with increased odds of inpatient mortality.

CONCLUSIONS

Intraoperative heparin use was associated with reduced inpatient mortality for patients undergoing TEVAR for BTAI, including those with major head or neck trauma and high ISSs. Heparin use did not increase the risk of hemorrhagic complications across all injury grades. Also, in patients with grade III BTAI, heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI and should be administered when no specific contraindication exists.

Blunt Thoracic Aortic Injury and Acute Trauma: The Effect on Aortic Diameter and the Consequences for Stent-graft Sizing

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.

Endovascular repair is a feasible option for superficial femoral artery injuries: a comparative effectiveness analysis

PURPOSE

To compare outcomes between open (OR) and endovascular repair following superficial femoral artery (SFA) injuries.

METHODS

This is a cross-sectional study querying the 2012-2014 National Inpatient Sample for SFA injuries. Patients were grouped into OR and stent-graft placement (SGP). Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), fasciotomy and amputation rate, and cost. Wilcoxon rank-sum, Kruskal-Wallis, Chi-squared test with Bonferroni adjustment were used as appropriate; p < 0.05 was significant.

RESULTS

255 Patients were identified. Mean age was 34.6 years and majority were males. OR was performed in 82.7%. Overall mortality rate was 3.7%. Median HLOS was 8 days. Fasciotomies were performed in 31% and lower limb amputations in 3.7%. Males more often underwent OR (89.0% vs. 73.1%, p < 0.01). SGP patients were significantly older (44.9 vs. 32.5 years; p < 0.01), and with Medicare insurance (20.5% vs. 6.5%; p < 0.01. Mortality, HLOS, and hospitalization cost were not significantly different. OR patients had higher rate of fasciotomy (35.4% vs. 15.4%; p < 0.01).

CONCLUSIONS

Endovascular management is not inferior to OR following SFA injuries and both carry a low amputation rate. OR is associated with a higher fasciotomy rate. Endovascular repair should be considered when technically feasible.

Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?

The clinical spectrum of pericardial effusions varies from innocuous serous fluid to life-threatening hemopericardium. A misdiagnosis may be made by similar clinical presentation of acute chest pain/hypotension. Echocardiography is the first-line test for diagnosis of pericardial effusion and its etiology, but sometimes there are different drawbacks to the correct cardiovascular ultrasound diagnosis. Radiologists are reporting an increasing amount of thoracic Multidetector CT examinations at the emergency department. Multidetector CT has now become an established and complementary method for cardiac imaging, and diseases of the pericardium can now be quickly identified with increasing certainty. The aim of this review is to discuss the hemopericardium key Multidetector CT features in acute clinical setting which indicate the need to proceed with predominantly medical or surgical treatment, however, being able to identify forms of bleeding pericardial effusion for which only "a watch and wait strategy" and/or deferred treatment is indicated. In the emergency care setting, radiologists must be aware of different findings of hemopericardium in order to address a tailored and timely management approach.

A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter?

BACKGROUND

Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS).

METHODS

The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05.

RESULTS

Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001).

CONCLUSION

For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Early Characteristics and Progression of Blunt Traumatic Aortic Injuries at a Single Level I Trauma Center

OBJECTIVES

The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined.

METHODS

Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups.

RESULTS

Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01).

CONCLUSIONS

While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.

A Case of Fatal Stanford Type A Aortic Dissection Caused by a Traffic Accident with Low Energy Impact

A seemingly healthy 84-year-old female pedestrian was mildly bumped by a car, and she hit her left shoulder, flank, and lower legs when she fell down on a street. She was conscious and stable when transferred to an emergency room. She had no sign of any major injuries except minor lacerations on her legs. Repeated evaluations including chest X-ray, ECG, and focused assessment with sonography for trauma did not reveal any abnormal findings. While waiting for discharge, she started having mild chest discomfort. Unexpectedly, the third echocardiogram showed mild pericardial effusion, and a CT with contrast showed aortic dissection in the ascending aorta and infra-left subclavian aortic dissection. She was immediately transferred by a helicopter to a tertiary trauma center for emergent repair surgery. Considering the site of dissections, progression of existing intrinsic intimal tear triggered by energy impact was suspected. However, traumatic causes could not be excluded. Extra caution and diligence should be exercised when examining elderly patients in blunt trauma.

Endovascular Treatment of a Life-threatening Blunt Thoracic Aortic Injury in Polytraumatized Patients - A Single Center Experience

A retrospective analysis of our group of patients, efficacy, safety and the results of endovascular treatment of descending thoracic aorta by using stentgraft implantation in polytraumatized patients. In the period between 6/2006 and 2/2020, in the processing of data, we analysed retrospectively patients with polytrauma diagnosed with thoracic aortic rupture or transection (TAT) and treated with multiple injuries. Clinical characteristics, complications, pathological features, and hospital follow-up data were retrieved from our group. In our group of 28 polytraumatized patients referred to our Trauma Centre with current TAT, all 28 patients with such a thoracic aortic injury were treated by using thoracic stentgraft implantation. In our group of patients, the average Injury Severity Score (ISS) was 22 for women (min 19, max 27) and 26 for men (min 17, max 41), respectively. We reached 100% technical implantation success rate with our patients. In our group, we had 30-day mortality of 10.7% (3 patients) and the in-hospital mortality was 17.8% (5 patients). Surviving patients had calculated ISS score of 25 (min 17, max 41); dead patients had an ISS score of 28 (min 19, max 34) - p≤0.05. Endovascular treatment of TAT, as a minimally invasive and effective procedure with rapid bleeding control, may increase survival chances for severely compromised polytraumatized patients in the context of multiple-organ damage and the need for a major cardio-vascular surgery.