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Liu Y, Sun L, Wang Q, Xiang B, Cai H, Xie Y, Li M, Xiang H. Delayed endovascular repair for traumatic aortic pseudoaneurysms: experience from an Asian single center. J Cardiothorac Surg 2023; 18:19. [PMID: 36631825 PMCID: PMC9835260 DOI: 10.1186/s13019-022-02078-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/10/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Traumatic aortic pseudoaneurysms (PSAs) classified as grade III aortic injuries are conventionally repaired as procedural emergencies, generally within 24 h of arrival. These patients typically require adequate resuscitation and treatment of multiple traumatic injuries, which complicate optimal management strategies of aortic PSAs. This study reviews the experience of an Asian single center to evaluate the efficacy and safety of delayed (> 24 h) endovascular repair for PSAs. METHODS Twenty-seven patients with blunt aortic injury (BTAI) were brought to our institution between February 2014 and May 2020. Patients with other grades of aortic injuries (grade I, II, or IV) were excluded from the study, and the remaining patients with grade III aortic injuries were placed into the early (< 24 h) and delayed (> 24 h) groups according to the timing of repair. Medical records and follow-up computed tomography (CT) scans were reviewed to document the outcomes of the procedures. Primary outcomes included mortality and complications. RESULTS During this period, there were 14 patients (13 males and 1 females) with aortic PSAs, and each patient received thoracic endovascular aortic repair (TEVAR). Of these 14 patients, 1 underwent emergent TEVAR, and 13 underwent delayed repair (median 7 days, range, 3-14 days). Over a period of 8 years, the overall survival of our series was 100%. No paraplegia, stroke, ischemia of limb or other serious procedural complications were observed during the duration of follow-up. CONCLUSION The experience of our center indicates that delayed repair for selected PSAs could be permissible, which enables a repair in more controlled circumstances.
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Affiliation(s)
- Yuzhou Liu
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Lin Sun
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Qing Wang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Bin Xiang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Huangxing Cai
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Yong Xie
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Muzi Li
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
| | - Hua Xiang
- grid.411427.50000 0001 0089 3695Department of Interventional Radiology and Vascular Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005 People’s Republic of China
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Park H, Shin TG, Kim WY, Jo YH, Hwang YJ, Choi SH, Lim TH, Hna KS, Shin J, Suh GJ, Kang GH, Kim KS, Korean Shock Society investigators. Current updates in acute traumatic aortic injury: radiologic diagnosis and management. Clin Exp Emerg Med 2022; 9:73-83. [PMID: 35843607 PMCID: PMC9288877 DOI: 10.15441/ceem.22.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 02/23/2022] [Indexed: 12/04/2022] Open
Abstract
Acute traumatic aortic injuries, which have substantial lethal outcomes at the time of admission, are fatal in 80% to 90% of cases. These injuries are relatively rare and have nonspecific clinical presentations. Radiologists and emergency physicians need to identify the radiological signs of acute traumatic aortic injury and differentiate them from common imaging errors to ensure accurate diagnosis and determine appropriate management protocols. In combination with image-guided interventions, advances in cross-sectional imaging have enabled nonsurgical management of acute traumatic aortic injuries. Timely and precise diagnoses of these injuries following prompt treatment are essential as up to 90% of patients presenting at the hospital can undergo early repair.
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Kapoor H, Lee JT, Orr NT, Nisiewicz MJ, Pawley BK, Zagurovskaya M. Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management. Radiographics 2020; 40:1834-1847. [PMID: 33006921 DOI: 10.1148/rg.2020200066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.
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Affiliation(s)
- Harit Kapoor
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - James T Lee
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Nathan T Orr
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Michael J Nisiewicz
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Barbara K Pawley
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
| | - Marianna Zagurovskaya
- From the Division of Emergency Radiology, Department of Radiology (H.K., J.T.L., B.K.P., M.Z.), Division of Vascular Surgery, Department of Surgery, (N.T.O.), and School of Medicine (M.J.N.), University of Kentucky Chandler Medical Center, 800 Rose St, HX315E, Lexington, KY 40536
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D'Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, Trimarchi S. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:681-696. [PMID: 32964899 DOI: 10.23736/s0021-9509.20.11580-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
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Affiliation(s)
- Ilenia D'Alessio
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Bissacco
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierantonio Rimoldi
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno Palmieri
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Romagnoli AN, Dubose JJ. Unmet needs in the management of traumatic aortic injury. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01429-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Romagnoli AN, Dubose J. Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:289-297. [PMID: 30855117 DOI: 10.23736/s0021-9509.19.10909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.
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Affiliation(s)
| | - Joseph Dubose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Harris DG, Rabin J, Crawford RS, Klyushnenkova EN, Drucker CB, Chen H, Scalea TM, Diaz JJ. Incidence and outcomes of thoracic aortic injuries with regionalized care in a mature trauma system. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408617738811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction Thoracic aortic injury is a leading cause of death after blunt trauma, but the effect of trauma system organization on outcomes is undefined. This was an analysis of thoracic aortic injury in a state with a comprehensive trauma system. Methods This was a retrospective study of thoracic aortic injury in Maryland between 2009 and 2014 using a statewide inpatient admission database. Presence of thoracic aortic injury and open or endovascular aortic interventions were identified by International Classification of Diseases version 9 codes. Patients were compared by admitting hospital status, categorized as Level I or non-Level I trauma centers. Outcomes were overall inpatient mortality and death after aortic repair. Results Of 774,211 injured patients, 168 (0.02%) had thoracic aortic injury. Patients with thoracic aortic injury were younger, more often male, and were more severely injured than patients without thoracic aortic injury. The majority of patients (136, 81%) were admitted to Level I trauma centers; Level I and non-Level I patients had similar characteristics. Most patients (110, 65%) were managed non-operatively, but patients admitted to Level I facilities were more likely to undergo aortic repair. Overall and post-operative mortality rates were lower at Level I hospitals (22% versus 31% and 6% versus 17%, respectively), but these differences did not reach statistical significance. Conclusion This novel analysis indicates thoracic aortic injury management in Maryland is highly concentrated at Level I trauma centers, which was associated with mortality below previously reported national rates. Although limited by small sample size, these findings suggest a benefit to regionalized care for patients with thoracic aortic injury and support transfer to high-volume facilities for definitive management.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Robert S Crawford
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- Center for Aortic Diseases, University of Maryland Medical Center, Baltimore, USA
| | - Elena N Klyushnenkova
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Charles B Drucker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Hegang Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Jose J Diaz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
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Abstract
Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.
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Affiliation(s)
- Joseph J Platz
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - Loic Fabricant
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Mitch Norotsky
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
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Weatherspoon K, Gilbertie W, Catanzano T. Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis. Semin Ultrasound CT MR 2017; 38:370-383. [PMID: 28865527 DOI: 10.1053/j.sult.2017.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.
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Affiliation(s)
- Kimberly Weatherspoon
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA.
| | - Wayne Gilbertie
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA
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Harris DG, Huffner ME, Croal-Abrahams L, DiChiacchio L, Farivar BS, Ayers JD, Toursavadkohi S, Rabin J, Crawford RS. Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery. Ann Vasc Surg 2017; 42:302.e15-302.e20. [PMID: 28390914 DOI: 10.1016/j.avsg.2016.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 12/12/2016] [Accepted: 12/19/2016] [Indexed: 11/18/2022]
Abstract
Blunt thoracic aortic injury (BTAI) in a patient with an aberrant right subclavian artery (ARSA) presents unique challenges for patient management and aortic repair. Specific considerations include the need to treat coincidental ARSA, subclavian revascularization, and ARSA exclusion. Despite the rise of endovascular repair as the primary modality for aortic repair for BTAI, reports of this technique in the setting of ARSA are limited. Here we describe 3 patients with ARSA who underwent TEVAR for BTAI, and discuss critical management and technical issues in these patients.
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Affiliation(s)
- Donald G Harris
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael E Huffner
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Luqman Croal-Abrahams
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Laura DiChiacchio
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Behzad S Farivar
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph D Ayers
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Joseph Rabin
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Robert S Crawford
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD.
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Gandhi SS, Blas JV, Lee S, Eidt JF, Carsten CG. Nonoperative management of grade III blunt thoracic aortic injuries. J Vasc Surg 2016; 64:1580-1586. [DOI: 10.1016/j.jvs.2016.05.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
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12
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Harris DG, Rabin J, Starnes BW, Khoynezhad A, Conway RG, Taylor BS, Toursavadkohi S, Crawford RS. Evolution of lesion-specific management of blunt thoracic aortic injury. J Vasc Surg 2016; 64:500-505. [DOI: 10.1016/j.jvs.2015.12.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/19/2015] [Indexed: 10/21/2022]
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Harris DG, Rabin J, Bhardwaj A, June AS, Oates CP, Garrido D, Toursavadkohi S, Khoynezhad A, Crawford RS. Nonoperative Management of Traumatic Aortic Pseudoaneurysms. Ann Vasc Surg 2016; 35:75-81. [PMID: 27263820 DOI: 10.1016/j.avsg.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current blunt thoracic aortic injury (BTAI) guidelines recommend early repair of traumatic pseudoaneurysms (PSAs) due to risk for subsequent aortic rupture. Recent analyses indicate that early repair is required only in the setting of high-risk features, while delayed repair is safe and associated with lower morbidity and mortality in appropriately selected patients. To evaluate the appropriate indications for nonoperative management (NOM) of traumatic PSAs, we performed a systematic review of studies reporting outcomes for this management strategy. We hypothesized that NOM is safe in appropriately selected patients with traumatic aortic PSAs. METHODS English language single- and multi-institutional series reporting NOM of traumatic thoracic aortic PSAs were identified by systematic literature search and review. A descriptive analysis was performed of NOM, with stratification by lesion size and patient follow-up. The primary outcomes were late aortic intervention, aortic-related death, and all-cause mortality. RESULTS Eighteen studies, which included 937 patients with traumatic PSAs, were analyzed. One hundred ninety-one patients were managed nonoperatively. The primary indication for NOM was prohibitive risk for aortic repair due to severe comorbidities or concurrent injuries. Where reported, PSAs with <50% circumferential involvement accounted for 88% of lesions selected for NOM. Late interventions were required in 4% of patients. Inpatient aortic-related mortality was 2%, and all-cause inpatient mortality was 32%. Although survival at up to 4-7 years was reported, postdischarge follow-up after PSA NOM was limited to <1 year in most studies. CONCLUSIONS NOM of traumatic aortic PSAs is a common practice in BTAI series reporting lesion-specific management, and is associated with low rates of treatment failure. These findings suggest that routine early repair may not be required for traumatic PSAs, particularly for lesions limited to <50% of the aortic circumference. Definitive repair can be delayed until patient stability and repair timing can be guided by assessment of lesion stability on follow-up imaging.
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Affiliation(s)
- Donald G Harris
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Joseph Rabin
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Abhishek Bhardwaj
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Angelina S June
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Connor P Oates
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Danon Garrido
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ali Khoynezhad
- Division of Cardiothoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert S Crawford
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
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Fortuna GR, Perlick A, DuBose JJ, Leake SS, Charlton-Ouw KM, Miller CC, Estrera AL, Azizzadeh A. Injury grade is a predictor of aortic-related death among patients with blunt thoracic aortic injury. J Vasc Surg 2016; 63:1225-31. [DOI: 10.1016/j.jvs.2015.11.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/12/2015] [Indexed: 11/27/2022]
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16
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Zaw AA, Stewart D, Murry JS, Hoang DM, Sun B, Ashrafian S, Hotz H, Chung R, Margulies DR, Ley EJ. CT Chest with IV Contrast Compared with CT Angiography after Blunt Trauma. Am Surg 2016. [DOI: 10.1177/000313481608200122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blunt aortic injury (BAI) after chest trauma is a potentially lethal condition. Rapid diagnosis is important to appropriately treat patients. The purpose of this study was to compare CT with intravenous contrast (CTI) to CT with angiography (CTA) in the initial evaluation of blunt chest trauma patients. This was a retrospective review of all blunt trauma patients who received a CTI or CTA during the initial evaluation at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Two-hundred and eighty-one trauma patients met inclusion criteria. Most, 167/281 (59%) received CTI and 114/281 (41%) received CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale in emergency department. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified an injury in 54 per cent compared with 46 per cent in CTA ( P = 0.05). Overall, 2 per cent of patients had BAI with similar rates in CTI and CTA (2% vs 2%, P = 0.80). BAI was not missed using either CTI or CTA. Trauma patients studied with CTI had similar diagnostic findings as CTA. CTI may be preferable to CTA during the initial assessment for possible BAI because of a single contrast injection for whole body CT.
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Affiliation(s)
- Andrea A. Zaw
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Donovan Stewart
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jason S. Murry
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David M. Hoang
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Beatrice Sun
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sogol Ashrafian
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Heidi Hotz
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rex Chung
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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17
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Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Nakanishi T, Ishida H. Blunt thoracic aortic injury with small pseudoaneurysm may be managed by nonoperative treatment. J Vasc Surg 2015; 63:341-4. [PMID: 26506935 DOI: 10.1016/j.jvs.2015.08.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The efficacy of nonoperative management of blunt thoracic aortic injury (BTAI) was evaluated in patients with pseudoaneurysm. METHODS A retrospective review was done for patients with BTAI at Fukui Prefectural Hospital during a 9-year period. Charts were reviewed for age, gender, Injury Severity Score, Abbreviated Injury Scale for each body area, initial type of aortic injury, site of aortic injury, type of definitive management, complications, and outcomes. RESULTS Eighteen patients with BTAI were treated at Fukui Prefectural Hospital. Of 18 patients with pseudoaneurysm, seven patients were hemodynamically unstable and four patients died because of associated injuries; there were no aortic-related deaths. All 14 surviving patients were followed up for an average of 40.9 months. Only two patients with pseudoaneurysm required operative management because of the progression of the pseudoaneurysm. The pseudoaneurysm/normal aortic diameter ratio of those with any intervention was higher than that of those with nonoperative management. CONCLUSIONS BTAI with pseudoaneurysm can be managed nonoperatively, with about 10% risk of progression to require surgical repair.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Aneurysm, False/diagnosis
- Aneurysm, False/mortality
- Aneurysm, False/physiopathology
- Aneurysm, False/therapy
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/injuries
- Aorta, Thoracic/physiopathology
- Aorta, Thoracic/surgery
- Aortography/methods
- Disease Progression
- Female
- Hemodynamics
- Humans
- Injury Severity Score
- Japan
- Male
- Middle Aged
- Retrospective Studies
- Thoracic Injuries/diagnosis
- Thoracic Injuries/mortality
- Thoracic Injuries/physiopathology
- Thoracic Injuries/therapy
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
- Vascular System Injuries/diagnosis
- Vascular System Injuries/mortality
- Vascular System Injuries/physiopathology
- Vascular System Injuries/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/physiopathology
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan.
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Makoto Sera
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideya Nagai
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Taizo Nakanishi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Ishida
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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18
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Mokrane FZ, Revel-Mouroz P, Saint Lebes B, Rousseau H. Traumatic injuries of the thoracic aorta: The role of imaging in diagnosis and treatment. Diagn Interv Imaging 2015; 96:693-706. [PMID: 26122129 DOI: 10.1016/j.diii.2015.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
Abstract
Traumatic injury of the thoracic aorta remains the leading cause of death in multiple trauma patients and it requires urgent management. Computed tomography has a key diagnostic role and allows the clinician to choose an appropriate treatment strategy. The development of new classifications, based on a better understanding of the mechanisms of these injuries, has clarified the indications for treatment. Advances in techniques, especially in endovascular management, have contributed to improving prognosis for patients. Interventional radiology, which usually consists of endovascular placement of a covered stent, now constitutes the gold standard treatment in these injuries. Due to the potentially grave prognosis of these patients, it is crucial to know how to detect these injuries and to describe the imaging signs of serious damage.
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Affiliation(s)
- F Z Mokrane
- Department of Radiology, CHU Rangueil Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
| | - P Revel-Mouroz
- Department of Radiology, CHU Rangueil Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - B Saint Lebes
- Department of Vascular Surgery, CHU Rangueil Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - H Rousseau
- Department of Radiology, CHU Rangueil Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
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