A 14-year experience with blunt thoracic aortic injury

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.

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.

Tension Hemothorax in Aortic Rupture: A Case Report

Background: The standard ATLS protocol calls for chest drain insertion in patients with hemothorax before performing further diagnostic steps. However, if trauma-induced thoracic aortic rupture is the underlying cause, such drainage can lead to massive bleeding and death of the patient. Case report: This report describes a case of a polytrauma patient (car accident), aged 21, with symmetrical chest and decreased breath sounds dorsally on the left. An urgent CT scan revealed subadventitial Grade III thoracic aortic transection with mediastinal hematoma, a massive left-sided hemothorax with mediastinal shift to the right, and other injuries. Stent-graft implantation with subsequent left hemithorax drainage was urgently performed, during which the patient became increasingly unstable from the circulatory point of view. This traumatic hemorrhagic shock was successfully managed at the ICU. Conclusion: Although hemothorax is a serious condition requiring rapid treatment, the knowledge of its origin is of utmost importance; performing chest drainage without bleeding control can lead to circulatory instability and death of the patient. Hence, where aortic injury can be suspected based on the mechanism of the injury, it is beneficial to perform spiral CT angiography for accurate diagnosis first and, in cases of aortic injury, to control the bleeding prior to drainage.

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.

ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury

Blunt cardiac injuries range from myocardial concussion (commotio cordis) leading to fatal ventricular arrhythmias to myocardial contusion, cardiac chamber rupture, septal rupture, pericardial rupture, and valvular injuries. Blunt injuries account for one-fourth of the traumatic deaths in the United States. Chest radiography, transthoracic echocardiography, CT chest with and without contrast, and CT angiography are usually appropriate as the initial examination in patients with suspected blunt cardiac injury who are both hemodynamically stable and unstable. Transesophageal echocardiography and CT heart may be appropriate as examination in patients with suspected blunt cardiac injuries. This publication of blunt chest trauma-suspected cardiac injuries summarizes the literature and makes recommendations for imaging based on the available data and expert opinion. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients

BACKGROUND

Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications.

METHODS

We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender.

RESULTS

We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I² = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I² = 52%; P = .03), 0% (95% CI, 0%-2.0%; I² = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I² = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I² = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I² = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I² = 65%; P < .01), 0% (95% CI, 0%-1.8%; I² = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I² = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I² = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (β = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (β = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (β = .54; 95% CI, 0.3-0.90).

CONCLUSIONS

This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review

BACKGROUND

Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an 'endovascular first' approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising 'off-the-shelf' stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury.

METHODS

We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549).

RESULTS

The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously.

CONCLUSIONS

Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.

National Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury

BACKGROUND

Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair.

METHODS

This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR.

RESULTS

We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19-2.23, P < 0.05).

CONCLUSIONS

The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.

The evolution of care improves outcome in blunt thoracic aortic injury: A Western Trauma Association multicenter study

BACKGROUND

The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular aortic repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI.

METHODS

Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between January 1, 2006, and June 30, 2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome.

RESULTS

We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). Thoracic endovascular aortic repair and open repair groups had similar Injury Severity Scale score, chest Abbreviated Injury Scale score, Trauma and Injury Severity Score, and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}, 19-51]; TEVAR: 46 [IQR, 28-60]; p < 0.007), zone of aortic injury (p < 0.001), and grade of aortic injury (open: 6 [IQR, 4-6]; TEVAR: 2 [IQR, 2-4]; p < 0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%; p = 0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%.

CONCLUSIONS

The mortality of BTAI continues to decrease. Thoracic endovascular aortic repair, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in computed tomography imaging in follow-up of TEVAR is warranted.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Long-term outcomes of thoracic endovascular aortic repair: A single institution's 11-year experience

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown.

METHODS

All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports.

RESULTS

A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively.

CONCLUSION

TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis

INTRODUCTION

To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications.

EVIDENCE ACQUISITION

PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted.

EVIDENCE SYNTHESIS

A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon.

CONCLUSIONS

TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.

Emergency endovascular management of acute thoracic aortic pathology A safe and feasible option

Endovascular repair has revolutionised the emergency treatment of thoracic aortic disease. We report our 10 year experience using this treatment in emergency cases. A prospectively maintained vascular database was analysed. Patients' medical records and CT images stored on the hospital PACS system were also reviewed. Statistical analysis was done using IBM SPSS V21. There were a total of 59 thoracic aortic stenting procedures of which 33 (60% males with a mean age of 58 yrs) were performed for emergency thoracic pathologies: traumatic transection (n = 10), ruptured aneurysm (n = 6), non-traumatic dissection (n = 8) and penetrating aortic ulcer (n = 9). All patients had self-expanding endografts implanted. Two patients required debranching procedures before the endovascular treatment. Thirty-day mortality was 12.1% (4/33). 70% of patients received a single device. There were 7 procedure related complications, 6 requiring re-intervention: thoracotomy and drainage in 2 patients, proximal graft extension in 2, open drainage of groin haematoma in 1 and open repair of a common femoral artery pseudo-aneurysm in one patient. In total 23 patients were transferred from 11 centres nationwide. There were no mortalities or other complications related to patient transfer from peripheral centres. Although acute thoracic aortic pathology is life threatening, appropriate blood pressure management and treatment of associated injuries can result in favourable outcomes. Endovascular repair is a safe and effective treatment option which enables patients to be treated with reduced morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed.

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries

BACKGROUND

Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally.

METHODS

Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality.

RESULTS

Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3).

CONCLUSIONS

TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.

Isolated blunt abdominal aortic injury without concomitant abdominal injuries treated with endovascular stent grafting

Blunt injury of the abdominal aorta is a rare event, seen in only 0.07% to 0.17% of all blunt traumas. These injuries are frequently associated with other intra-abdominal injuries, with high rates of morbidity and mortality. We present a case of isolated blunt abdominal aortic trauma to the infrarenal aorta without concomitant abdominal or spinal injuries. The patient was treated with endovascular aortic stent grafting and is without complications 12 months after the procedure.

Advances in the treatment of blunt thoracic aortic injuries

Blunt thoracic aortic injuries, even though rare in incidence, carry significant mortality rates and their management still remains challenging. There have been major shifts in diagnosing and treating these injuries in the last 5 decades, which proved to be beneficial in terms of mortality and complications. Endovascular repair has been increasingly used for definitive treatment and its outcomes appear to be at least equally safe and effective as those of open repair. We present a balanced review of the relevant literature regarding the most appropriate approach and definitive treatment of these pathological entities. Based on the studies analyzed, endovascular repair is increasingly being established as the choice of treatment, however, the conventional open surgical approach still remains a safe method for severe injuries; the mortality, complication rates and proven longterm results of the latter are continuously improving. Additionally, delayed repair, where appropriate, seems to be a safe option with very low mortality rates. Despite the encouraging short and midterm outcomes reported, endovascular treatment needs to be assessed in the longterm for more accurate conclusions to be drawn about its durability and safety.

Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review

BACKGROUND

Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT.

METHODS

A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers.

RESULTS

We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0-33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0-45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0-12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50-100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0-14.9) versus 11.9% (89 of the 745, range 0-33.3) respectively.

CONCLUSION

The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.

Blunt aortic injury: risk factors and impact of surgical approaches

PURPOSE

This study reviews our 17-year experience of managing blunt traumatic aortic injury (BTAI).

METHODS

We analyzed information collected retrospectively from a tertiary trauma center.

RESULTS

Between October 1995 and June 2012, 88 patients (74 male and 14 female) with a mean age of 39.9 ± 17.9 years (range 15-79 years) with proven BTAI were enrolled in this study. Their GCS, ISS, and RTS scores were 12.9 ± 3.7, 29.2 ± 9.8, and 6.9 ± 1.4, respectively. Twenty-one (23.8 %) patients were managed non-operatively, 49 (55.7 %) with open surgical repair, and 18 (20.5 %) with endovascular repair. The in-hospital mortality rate was 17.1 % (15/81) and there were no deaths in the endovascular repair group. The mean follow-up period was 39.9 ± 44.2 months. The survivors of blunt aortic injury had lower ISS, RTS, TRISS, and serum creatinine level and lower rate of massive blood transfusion, shock, and intubation than the patients who died, despite higher rates of endovascular repair, hemoglobin, and GCS on presentation. The degree of aortic injury, different therapeutic options, GCS, shock presentation, and intubation on arrival all had significant impacts on outcome.

CONCLUSIONS

Shock, aortic injury severity, coexisting trauma severity, and different surgical approaches impact survival. Endovascular repair achieves a superior mid-term result and is a reasonable option for treating BTAI.

Endovascular treatment of distal thoracic aortic transection associated with severe thoracolumbar spinal fracture

Endovascular repair has become the first line of treatment in most patients with blunt aortic injury. The most common mechanism is deceleration injury affecting the aortic isthmus distal to the origin of the left subclavian artery. Injuries of the distal thoracic aorta are uncommon. We report the case of a 25-year-old male patient who presented with paraplegia and distal thoracic aortic pseudoaneurysm associated with severe thoracolumbar vertebral fracture and displacement after a motocross accident. Endovascular repair was performed using total percutaneous technique and conformable C-TAG thoracic stent-graft (WL Gore, Flagstaff, AZ). Following stent-graft placement and angiographic confirmation of absence of endoleak, thoracolumbar spinal fixation was performed in the same operative procedure. This case illustrates a multispecialty approach to complex aortic and vertebral injury and the high conformability of newer thoracic stent-grafts to adapt to tortuous anatomy.