Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery

Long-Term Survival and Reintervention Following Thoracic Endovascular Aortic Repair in Blunt Traumatic Thoracic Aortic Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI.

MATERIAL AND METHODS

A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4.

RESULTS

1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I2 = 70.6%). This was 91% (95% CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I2 = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I2 = 81.7%).

CONCLUSIONS

Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities.

Gunshot wound causing thoracic aortic injury with bullet embolization to the common femoral artery

Penetrating traumatic aortic injury (PTAI) is increasing in prevalence given the rise in firearm violence in the United States and is associated with significant morbidity and mortality. These injuries often result in hemorrhagic shock, with patients presenting in extremis or pulseless, traditionally requiring open approaches for repair. A rare but potentially devastating complication of firearm-related PTAI is bullet embolization. This case report describes the successful resuscitation and endovascular treatment of a patient with a firearm-induced PTAI complicated by acute limb ischemia secondary to bullet arterial embolization to the common femoral artery requiring arteriotomy for bullet removal.

Concordance between humans and GPT-4 in appraising the methodological quality of case reports and case series using the Murad tool

BACKGROUND

Assessing the methodological quality of case reports and case series is challenging due to human judgment variability and time constraints. We evaluated the agreement in judgments between human reviewers and GPT-4 when applying a standard methodological quality assessment tool designed for case reports and series.

METHODS

We searched Scopus for systematic reviews published in 2023-2024 that cited the appraisal tool by Murad et al. A GPT-4 based agent was developed to assess the methodological quality using the 8 signaling questions of the tool. Observed agreement and agreement coefficient were estimated comparing published judgments of human reviewers to GPT-4 assessment.

RESULTS

We included 797 case reports and series. The observed agreement ranged between 41.91% and 80.93% across the eight questions (agreement coefficient ranged from 25.39 to 79.72%). The lowest agreement was noted in the first signaling question about selection of cases. The agreement was similar in articles published in journals with impact factor < 5 vs. ≥ 5, and when excluding systematic reviews that did not use 3 causality questions. Repeating the analysis using the same prompts demonstrated high agreement between the two GPT-4 attempts except for the first question about selection of cases.

CONCLUSIONS

The study demonstrates a moderate agreement between GPT-4 and human reviewers in assessing the methodological quality of case series and reports using the Murad tool. The current performance of GPT-4 seems promising but unlikely to be sufficient for the rigor of a systematic review and pairing the model with a human reviewer is required.

The optimal management of blunt aortic injury in the young

BACKGROUND

Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset.

METHODS

Patients (1-19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1-9] and adolescents [ages 10-19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI.

RESULTS

Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 ​%, p ​= ​0.057) and significantly reduced mortality (2.1 vs 14.4 ​%, p ​< ​0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059-0.324, p ​< ​0.0001).

CONCLUSIONS

BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.

Blunt Thoracic and Abdominal Aortic Injury in Multiple Trauma: A Case Report

BACKGROUND

Blunt abdominal aortic injury (BAAI) is rare among traumatic aortic injuries, and further complications of blunt thoracic aortic injury (BTAI) have never been reported.

CASE PRESENTATION

A man in his 80s presented to our hospital following a motor vehicle accident. Pan-scan contrast-enhanced CT showed a thoracic aortic isthmus injury (Grade III), an abdominal aortic injury (Grade IV) with extravasation of contrast media at the level of the fourth lumbar vertebra. Endovascular abdominal aortic repair was performed on the same day and a thoracic endovascular aortic repair for BTAI was performed 11 days after admission. The patient had a good postoperative course and was discharged without complications.

CONCLUSION

This report presented a rare case of BTAI complicated with BAAI. The timing of intervention for aortic injury should be determined based on urgency and other organ damage.

Effects of Timing of Repair on Mortality Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

BACKGROUND

Blunt thoracic aortic injuries (BTAIs) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated.

METHODS

All patients with Grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multicenter registry from 2015 to 2022 were categorized dependent on timing of repair (early repair [ER] < 24 hours, late repair > 24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality.

RESULTS

Two hundred and twenty two Grade 2 and 3 BTAI treated by TEVAR were analyzed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale, age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. Thirty-day in-hospital mortality occurred in 14 patients (6%), 2 of which were aortic-related. Thirty-day mortality was associated with a higher baseline incidence of coronary artery disease/peripheral vascular disease/previous cardiac revascularization; lower systolic blood pressure, Glasgow Coma Scale, hemoglobin, platelet count, and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower hemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (P < 0.05), although time to TEVAR was not.

CONCLUSIONS

In selected patients, delay in performance of TEVAR for Grade 2 and 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success.

Traumatic Thoracic Aortic Coarctation after Blunt Thoracic Aortic Injury Mandates Emergent Thoracic Endovascular Aortic Repair

OBJECTIVE

This study sought to elucidate clinical and imaging findings predictive for malperfusion syndrome after blunt thoracic aortic injury (BTAI).

BACKGROUND

There is limited literature on malperfusion syndrome after BTAI, and the timing of thoracic endovascular aortic repair (TEVAR) in patients with this condition has not been defined.

METHODS

A retrospective analysis of prospectively collected data of patients with BTAI treated between January 2021 and October 2023. Clinical and thoracic aortic (TA) imaging data, time to TEVAR, in-hospital death, and malperfusion/reperfusion sequelae (paraplegia, renal/visceral/limb ischemia, and compartment syndromes) were assessed. Correlations between clinical and imaging findings, time to TEVAR, and outcomes were evaluated.

RESULTS

Of the 19,203 trauma patients evaluated, 13,717 (71%) had blunt injuries and 77 (0.6%) had BTAI. The majority (67.5%) were male, with a median age of 40 years (IQR: 33-55). TEVAR was performed in 42 (54.5%) patients. Seven (9.1%) patients presented with clinical and TA imaging criteria for traumatic thoracic aortic coarctation (TTAC), including diminished/absent femoral pulses and TA luminal narrowing of 50% to 99%. The median time to TEVAR was 9 (IQR: 5-32), 11, and 4 hours for all non-TTAC and TTAC BTAI patients, respectively ( P =0.037). Only TTAC patients presented/developed malperfusion/reperfusion sequelae. In-hospital mortality rates were 7.8%, 5.8%, and 29% for all non-TTAC and TTAC BTAI patients, respectively ( P =0.09). Aortic-related mortality occurred in only 2 (2.6%) TTAC patients.

CONCLUSIONS

Patients with clinical and TA imaging manifestations of TTAC are predisposed to malperfusion/reperfusion sequelae if TEVAR is delayed. We recommend the emergent repair of all BTAIs with TTAC.

Endovascular Aortic Repair in Traumatic Descending Thoracic Aortic Transection: A Case Report

Aortic transection, a near-complete tear through the layers of the aorta, is a critical condition often resulting from trauma such as motor vehicle collisions. The urgency of managing aortic transection underscores the critical need for effective interventions. We report the case of a male in his early 50s with no significant medical history who presented to the emergency department following a motor vehicle collision, sustaining multiple injuries including a descending thoracic aortic transection. Rapid diagnostic assessment confirmed the severity of the injury, necessitating immediate intervention. Endovascular aortic repair was successfully employed, highlighting its efficacy in managing acute aortic injuries. The patient responded well to treatment, underscoring the importance of timely intervention in improving patient outcomes. This case emphasizes the critical role of rapid diagnostic assessment and endovascular intervention in managing life-threatening thoracic aortic injuries, particularly in the acute setting.

The Year in Aortic Surgery: Selected Highlights From 2023

This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.

Unstable Spinal Fracture With Arteria Lusoria: Management to Mitigate Aortic Risks

Aortic injuries associated with unstable spinal fractures are a rare but serious condition, with high mortality. Rapid and multidisciplinary management is crucial to prevent fatal complications. We report the case of a female patient who, following a road traffic accident, presented with a displaced fracture of the fourth dorsal vertebrae (D4), with a detached anterior fragment adjacent to the posterior aspect of the aortic arch and the origin of the arteria lusoria. The multidisciplinary discussion concluded that surgery without an aortic prosthesis is associated with a major hemorrhagic risk due to aortic injury during spinal fixation manipulations, and surgery with a prosthesis is associated with immediate risks of ischemic cerebrovascular accident, gas embolism, and upper limb ischemia. We opted to prepare the patient for spinal stabilization surgery after placing the aortic prosthesis type: Zenith Alpha ZTA-PT-30-26-108 thoracic prosthesis (Cook Medical, Bloomington, Indiana, US). Our team's therapeutic approach is being discussed given the rarity of cases in the literature and the patient's anatomical characteristics. Surgical management in these situations must repair the unstable fracture while avoiding the aggravation of an existing or potential aortic injury. The aortic lesion can be treated first, before spinal fixation, either with open surgery, which carries a high risk of severe complications, or thoracic endovascular repair (TEVAR), which allows the prevention of the potential aortic injury or repair of the existing aortic injury while minimizing the side effects of open surgery. However, endovascular surgery may have limitations due to individual vascular anatomy, as in our patient's case, which can prevent optimal endograft positioning and lead to risks such as endoleak, ischemia, infection, or thrombosis, necessitating periodic radiological follow-up. Endovascular repair is a new paradigm that has improved clinical outcomes for these patients by securing the vascular injury first before spinal surgery. Teamwork and multidisciplinary discussion ensure optimal safety, minimizing the side effects of these lesions, which can be fatal at any time during management.

Evaluating the effectiveness of immediate vs. elective thoracic endovascular aortic repair for blunt thoracic aortic injury

PURPOSE

To evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis.

METHODS

This is a single-center retrospective cohort study. Patients who received TEVAR for BTAI at our institution from October 2016 to September 2023 were divided into 2 categories depending on the injury severity score (ISS) (≤ 25 vs. > 25) and when the TEVAR was performed for BTAI (within 24 h vs. after 24 h), respectively. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography. Patients treated with open repair and non-operative management were excluded. After propensity-score matching for various factors, outcomes during hospitalization and follow-up were compared. These factors included demographics, comorbidities, concomitant injuries, cause and location of aortic injury, Glasgow coma scale score, society for vascular surgery grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission. The comparison was conducted using SPSS 26 software. Continuous variables were presented as either the mean ± standard deviation or median (Q1, Q3), and were compared using either the t-test or the Mann-Whitney U test. Categorical variables were expressed as n (%), and comparisons were made between the 2 groups using the χ2 test or Fisher's exact test. Statistical significance was defined as a 2-sided p < 0.05.

RESULTS

In total, 110 patients were involved in the study, with 65 (59.1%) patients having ISS scores > 25 and 32 (29.1%) receiving immediate TEVAR. The perioperative overall mortality rate in the group with ISS > 25 was significantly higher than that in the group with ISS ≤ 25 (11 (16.9%) vs. 2 (4.4%), p < 0.001). Upon admission, the elective group exhibited a notably higher Glasgow coma scale score (median (Q1, Q3)) compared to the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039), while the creatinine concentration (median (Q1, Q3)) at admission was significantly higher in the immediate group (90.5 (63.8, 144.0) vs. 71.5 (58.3, 80.8), p = 0.012). The final sample included 52 matched patients. Complications occurred significantly less frequently in the elective group compared to the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Single-factor analysis of variance showed that complications in hospitalized patients were significantly associated with immediate TEVAR as the sole independent risk factor (odds ratio: 9.000, 95% confidence interval: 2.266 - 35.752, p = 0.002).

CONCLUSION

In this propensity-score matched analysis of patients undergoing TEVAR for BTAI, elective TEVAR was significantly associated with a lower risk of complication rates. In this study using propensity-score matching, patients who underwent elective TEVAR for BTAI had lower complication rates than immediate TEVAR.

Two cases of complex traumatic aortic dissection combined with multiple organ injuries

Traumatic aortic injury (TAI) is an acute, critical, and severe disease, and then combined with multiple organ damage, it is even more dangerous. TAI progresses very rapidly, with a pre-hospital mortality rate of 57% - 80%, and even when arriving at the hospital, more than one-third of the patients die within 4 h, and it is the 2nd leading cause of death in individuals aged 4 - 34 years. In addition, the incidence of TAI combined with injury was 81.4%. Therefore, early diagnosis, expeditious surgery, and timely and effective multidisciplinary cooperation are essential for successful rescue. The authors report 2 patients with acute traumatic aortic dissection combined with multiple organ injuries and treated with emergency endovascular surgery to discuss their clinical characteristics and treatment experience, and to provide experience in the diagnosis and treatment of such patients.

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.

Optimal Sizing of Aortic Stent Graft for Blunt Thoracic Aortic Injury Considering Hypotension-Related Decrease in Aortic Diameter

PURPOSE

To evaluate the optimal sizing of an aortic stent graft in patients with blunt thoracic aortic injury (BTAI), considering the decrease in diameter in hypovolemic status.

MATERIALS AND METHODS

From 2014 to 2020, 25 patients who underwent thoracic endovascular aortic repair (TEVAR) for BTAI were included. Hemodynamic parameters in the emergency room (ER) and just before the main procedure (MP) were collected. The aortic sizes were measured during initial computed tomography (CT) on arrival in the ER, aortography (AG) during TEVAR, and final CT in the outpatient clinic. The appropriateness of the inserted stent graft size was investigated.

RESULTS

The mean values of the final CT/initial CT and final CT/initial AG (proximal descending thoracic aorta [pDTA]) were 113% and 105%, respectively. The final CT/initial CT (pDTA; 122.2% vs 108.8%, p=0.01) and final CT/initial AG (pDTA; 113.4% vs 102.1%, p<0.01) were significantly higher in patients with systolic blood pressure (SBP; MP) ≤90 mm Hg. The final CT/initial CT (pDTA; 120.4% vs 109.0%, p=0.03) and final CT/initial AG (pDTA; 111.4% vs 102.6%, p=0.01) were significantly higher in patients with mean blood pressure (MBP; MP) ≤70 mm Hg. On an average, the inserted stent grafts were oversized by 130% on initial AG. Based on the final CT scan, the inserted stent graft was as large as 122%.

CONCLUSION

In the case of hemodynamic instability with SBP (MP) ≤90 mm Hg or MBP (MP) ≤70 mm Hg, despite adequate resuscitation, an oversized TEVAR stent graft of 130% can reduce the occurrence of endoleak and is sufficiently safe.

CLINICAL IMPACT

Despite sufficient resuscitation, the aorta size measured during TEVAR in patients with hemodynamic instability with systolic BP <90 mmHg and mean BP <70 mmHg may be reduced by more than 15% compared to that in the normal state. In this study, the mean size of the stent grafts were oversized by 130% on initial aortography, but were oversized by 122% based on final CT. When the stent graft was oversized by 130% in TEVAR for hemodynamic unstable patient with BTAI, the patient reached the proper oversizing subsequent to hemodynamic recovery.

[Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction]

AIM

The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations.

METHOD

A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options.

RESULTS

The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival.

CONCLUSION

Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

Successful management of a delayed presentation of traumatic descending thoracic aorta pseudoaneurysm: a literature review based on a case report

BACKGROUND

Blunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients' clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches. Case presentation The patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up.

CONCLUSION

Although open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events.

CLINICAL KEY POINT

Patients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient's clinical condition and evaluated anatomy in cardiovascular imaging.

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

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.

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage.

METHODS

This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up.

RESULTS

A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38).

CONCLUSION

In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Computed Tomography Angiography for Aortic Diseases

Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience

OBJECTIVE

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI).

MATERIALS AND METHODS

From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter.

RESULTS

Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed.

CONCLUSIONS

Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta.

CLINICAL IMPACT

This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Two-year follow-up after treatment of an aortic transection in the presence of an aberrant right subclavian artery

OBJECTIVES

An aberrant right subclavian artery (ARSA) is one of the most common anatomic variants of the aortic arch. The combination of an ARSA and a transection is naturally rare.

METHODS

This case report describes the treatment of a transection in the presence of an ARSA and the follow-up of two years.

RESULTS

We successfully treated the contained rupture with a stentgraft. Both subclavian arteries had to be covered in the emergency setting. At the two-year follow-up, the patient did not suffer from any neurological impairment.

CONCLUSIONS

In emergency settings, primary cover of both subclavian arteries with a stentgraft can be performed in individual cases after risk assessment. Severe complications such as development of upper limb ischaemia, ASAS or reduced perfusion of the posterior cerebral circulation should be considered in treatment planning.

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury

PURPOSE

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI.

METHODS

Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD).

RESULTS

We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001).

CONCLUSION

We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.

A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI.

METHOD

This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria.

RESULTS

Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up.

CONCLUSION

Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

Clinical study of reoperation for acute type A aortic dissection

Objective

The initial operation for type A aortic dissection has limitations, and there may be a need for reoperation in cases such as giant pseudoaneurysm formation and reduced blood supply to the distal vessels. In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience.

Method

Between June 2018 and December 2022, 62 patients with type A aortic dissection (TAAD) underwent reoperation after previous surgical treatment. Of these, 49 patients (45 males) underwent endovascular aortic repair (EVAR) with a mean age of (49.69 ± 10.21) years (30-75 years), and 13 patients (11 males) underwent thoracoabdominal aortic replacement (TAAR) with a mean age of (41.00 ± 11.18) years (23-66 years). In this study, we retrospectively analyzed the recorded data of 62 patients. In addition, we summarized and analyzed their Computed Tomographic Angiography (CTA) results and perioperative complications.

Outcome

In the EVAR group, 47 patients (95.92%) were successfully implanted with overlapping stents, and 2 patients died in the perioperative period. Postoperative complications included cerebral infarction (4.08%), acute renal insufficiency (30.61%), pulmonary insufficiency and need for ventilator (6.12%), poor wound healing (2.04%), postoperative reoperation (16.33%), and lower limb ischemia (2.04%). In the TAAR group, 12 patients (92.31%) were successfully revascularized and 1 patient died in the perioperative period. Postoperative complications included cerebral infarction (7.69%), acute kidney injury (46.15%), pulmonary insufficiency and need for ventilator (15.38%), poor wound healing (30.77%) and postoperative reoperation (15.38%).

Conclusion

According to the results of the study, compared with TAAR, EVAR was less invasive, faster recovery, and offered a better choice for some high-risk and high-age patients with comorbid underlying diseases. However, the rate of revascularization was higher after EVAR than TAAR due to vascular lesions. Compared with the use of ascending aortic replacement + hemi-aortic arch replacement for acute type A aortic dissection in many countries and regions, the use of ascending aortic replacement + aortic arch replacement + elephant trunk stent is more traumatic in China, but facilitates reoperation. For young patients, the choice of treatment should be individualized combining vascular lesions and long-term quality of life.

The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury

OBJECTIVE

Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI.

METHODS

Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes.

RESULTS

Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission.

CONCLUSIONS

Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.

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.

Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results

OBJECTIVE

This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up.

METHODS

During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter.

RESULTS

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up.

CONCLUSIONS

Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

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.

Twenty-year United States national, demographic and regional mortality trends from traumatic thoracic aortic injury, 1999 to 2019

INTRODUCTION

Traumatic Thoracic Aortic Injury (TTAI) is associated with high mortality rates and is the second leading cause of death in traumatic patients. There has been a considerable advancement in the management of TTAI with novel and improved surgical procedures and imaging modalities. The aim of this study was to determine the national demographic and regional trends in mortality associated with TTAI in the United States across twenty years, 1999 to 2019.

METHODS

The multiple cause of death data on Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) database was utilized to query death certificates for TTAI from 1999 to 2019, in the United States. The International Classification of the Diseases, Tenth Revision (ICD-10) code S25.0 was used to identify and abstract data for TTAI related deaths. The data was further abstracted based on age, race, gender and Census-Bureau defined regions. The age-adjusted mortality rate (AAMR) per 100,000 population-year and Average Annual Percentage Change (AAPC) with 95 % Confidence Interval were computed. The JoinPoint software was utilized to compute the temporal trends in mortality based on a segmented change and AAPC calculation.

RESULTS

A total of 20,842 TTAI associated deaths occurred from 1999 to 2019 corresponding to an AAMR of 0.407(0.401-0.412) per 100,000 population-year. The overall AAMR reduced from 0.759 to 0.223 per 100,000 population-year from 1999 to 2019[average APC -6.5(-7.5; -5.5)]. The reduction was reported in both <45 age group [average APC -6.5(-7.9; -5.1)] and >45 age group [-6.2(-7.3; -5.0)]; among females [average APC -6.1(-7.8; -4.3)] and males [-6.1(-7.2; -5.0)]; among Whites [average APC -6.9(-7.8; -5.9)] and Blacks [-5.0(-7.4; -2.5)]. The reduction in mortality as per the census region was highest in the west followed by Mid-West, North-East and South [average APC -6.8(-8.6; -5.0); -6.2(-8.8; -3.6); -5.7(-7.0; -4.4); -5.5(-7.4; -3.6), respectively].

CONCLUSION

There was a significant decrease in the TTAI associated mortality trends in the United States across 1999-2019 with a consistent decline in all demographic and regional subgroups.

Traumatic Aortic Dissection as a Unique Clinical Entity: A Single-Center Retrospective Study

BACKGROUND

This study aimed to compare the clinical characteristics, treatment approaches, and outcomes of the Stanford Type B traumatic aortic dissection (TAD) with non-traumatic aortic dissection (NTAD), and assess better management for TAD.

METHODS

We retrospectively analyzed patients who underwent thoracic endovascular aortic repair for Stanford type B aortic dissection at The First Hospital of China Medical University between 2014 and 2022. The patients were divided into TAD and NTAD groups based on whether they had a history of acute trauma. This study ultimately included 65 patients with TAD and 288 with NTAD. We assessed and compared the baseline characteristics, laboratory indicators, imaging features, surgical procedures, and follow-up results between the groups.

RESULTS

The TAD group was younger compared to the NTAD group (50.00 [IQR40.00-59.00] vs. 55.00 [IQR 47.00-61.00] years, p = 0.020). A lower percentage of the TAD group had a history of hypertension (20% vs. 71.18%, p < 0.001). The length of aortic dissection was shorter in the TAD group compared to the NTAD group (30.00 [IQR 22.00-40.00] vs. 344.00 [IQR 237.25-400.00] mm, p < 0.001). All patients with TAD underwent TEVAR following the same strategy as NTAD. The mean preoperative duration was 7.00 (IQR 2.00-14.00) days in the TAD group and 11.00 (IQR 8.00-15.00) days in the NTAD group (p < 0.001). TAD showed fewer complications after TEVAR in mid-to-long-term follow-up.

CONCLUSIONS

TAD is distinct from NTAD. TAD typically presents with more localized lesions than NTAD, and the patients experience a shorter preoperative duration and a better mid-to-long-term outcome.

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.

Atypical presentation of subclavian steal syndrome with left sided sensorineural deafness

We present a rare manifestation of a common pathology: left sided sensorineural hearing loss secondary to subclavian steal syndrome after thoracic endovascular aortic repair for complicated acute aortic dissection. We describe the vascular physiology that can result in unilateral hearing loss and provide a brief review of subclavian steal syndrome. This case report highlights the importance of avid clinical recognition of an atypical presentation of a common vascular disease.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection

OBJECTIVE

The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications.

METHODS

The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia).

RESULTS

Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis.

CONCLUSIONS

In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.

Selective Arterial Catheterization as a Bridging Therapy for Blunt Traumatic Aortic Injury With Intraperitoneal Organ Malperfusion

Blunt thoracic aortic injury (BTAI) is fatal and requires thoracic endovascular aortic repair (TEVAR) for its optimal management. Performing TEVAR requires multidisciplinary specialists and supportive facilities.  We report a case of an 89-year-old man who presented to the emergency department with blunt trauma. Whole-body computed tomography (CT) revealed grade II aortic injury with disrupted blood flow to the left kidney. Sudden paralysis of the left lower extremity and distal progression of the aortic dissection occurred. However, TEVAR could not be performed immediately. Therefore, an external shunt from the right common femoral artery to the left lower extremity was created with angioplasty, superior mesenteric artery (SMA) stenting, and celiac artery (CA) balloon dilatation. The patient's condition stabilized, and he was transferred to a hospital where TEVAR was performed. Selective arterial catheterization (SAC) for treating intraperitoneal organ malperfusion caused by BTAI may be an effective bridging therapy for TEVAR.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

Case report: Endovascular stent-graft repair of aortic penetrating trauma, literature review, and case report

Penetrating aortic injuries are infrequent. Its incidence is unknown because most patients die of hemorrhage even before they receive adequate treatment. Aortic wounds generally require conventional thoracotomy/laparotomy repair and are related to high mortality rates. Recently with the advent of endovascular techniques, most authors prefer endovascular management when feasible due to better (still poor) outcomes. The short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are promising, especially when compared with open surgical treatment, indicating that endovascular therapy is preferable in patients with multi-trauma and traumatic ruptures of the thoracic aorta. Here we present the diagnosis and treatment of a 30 years-old male patient with multiple traumatic stab wounds, including anterior aortic laceration with a grade II aortic lesion successfully managed with an endovascular stent graft.

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.

Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair

INTRODUCTION

Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE.

METHODS

We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE.

RESULTS

Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process.

CONCLUSION

Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis

OBJECTIVE

We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration.

BACKGROUND

Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking.

METHODS

Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification.

RESULTS

Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group.

CONCLUSION

In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results

AIM

Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery.

MATERIALS AND METHODS

Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period.

RESULTS

The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I.

CONCLUSION

TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA.

CLINICAL IMPACT

Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

MRI detects increased aortic stiffening and myocardial dysfunction after TEVAR of blunt injury in young patients

Background: Thoracic endovascular aortic repair (TEVAR) is a well-established technique for the management of blunt thoracic aortic injury (BTAI). Despite improvements in vascular imaging, graft material properties, and implant techniques, stent-graft deployment artificially induces aortic stiffening. This study aimed to evaluate the midterm effect of thoracic endovascular aortic repair after blunt thoracic aortic injury on aortic stiffness and cardiac function in young patients using cardiovascular magnetic resonance (CMR) imaging. Patients and methods: From all patients who underwent TEVAR for BTAI between 2009 and 2019 in a single institution, 10 patients with no other comorbidities affecting arterial stiffness were sex-, age-, height-, and body surface area-matched to 10 healthy controls. Comprehensive CMR examination was performed in all controls and patients. The mean follow-up period was 5.4±1.8 years; the mean age at the time of TEVAR was 30.3±8.7 years. Results: Four patients who underwent TEVAR developed arterial hypertension. 4D flow CMR-based analysis demonstrated higher global pulse wave velocity (PWV) in TEVAR patients than in controls (p=0.012). Segmental analysis showed a higher PWV in the descending and abdominal aorta. The indexed diameter of the ascending aorta was larger in TEVAR patients than in controls (p=0.007). The CINE acquisitions demonstrated increased left ventricular myocardial thickness (p<0.001). The 3D global diastolic strain rate and diastolic longitudinal velocity (e') decreased, and the A-wave velocity increased. Native myocardial T1 values were significantly higher in TEVAR patients (p=0.037). Conclusions: Young patients with TEVAR after BTAI are at an increased risk of developing vascular and myocardial dysfunction due to increased aortic stiffness. CMR follow-up allows for a comprehensive and radiation-free evaluation of vascular stiffness and associated myocardial changes, especially at the early and subclinical stages.

Gore cTAG sleeve-associated maldeployment for traumatic aortic injury with aberrant right subclavian artery

A 30-year-old woman presented following a motor vehicle collision with a grade III blunt thoracic aortic injury and an aberrant right subclavian artery. Using intraoperative ultrasound and diagnostic subtraction angiography, we deployed an aortic endograft (cTAG; W.L. Gore & Associates), excluding the injury and aberrant right subclavian artery. The patient immediately lost arterial waveforms in her left arm, confirming incidental coverage of the left subclavian artery, likely due to the polytetrafluoroethylene sheath of the endograft. Her pulses returned after placement of a left subclavian chimney via retrograde brachial artery access.

Management of Vascular Injuries in Penetrating Trauma

Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).