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Rudra P, Cardoso R, Echevarria S, Kaya B, Abdullah R, Baskara Salian R, Bhindar SZ, Zerin A, Patel T, Abdin Z, Al-Tawil M. Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e41078. [PMID: 37519486 PMCID: PMC10375940 DOI: 10.7759/cureus.41078] [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: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.
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Affiliation(s)
- Pranathi Rudra
- Internal Medicine, Gandhi Medical College, Secunderabad, IND
| | - Rayner Cardoso
- Medical School, All India Institue of Medical Sciences, Jodhpur, IND
| | | | - Berfin Kaya
- Obstetrics and Gynaecology, Faculty of Medicine, Izmir Kâtip Celebi University, Izmir, TUR
| | - Ramal Abdullah
- Medical School, Foundation University Medical College, Foundation University School of Health Sciences (FUSH), Islamabad, PAK
| | | | - Shah Zaib Bhindar
- Orthopaedic Surgery, Ghurki Trust and Teaching Hospital, Lahore, PAK
| | - Annu Zerin
- Internal Medicine, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Tirath Patel
- Medical School, American University of Antigua, St. John's, ATG
| | - Zain Abdin
- Critical Care Medicine, IMG Helping Hands, Albuquerque, USA
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Gennai S, Leone N, Mezzetto L, Veraldi GF, Santi D, Spaggiari G, Resch T, Silingardi R. Systematic review and meta-analysis of long-term reintervention following thoracic endovascular repair for blunt traumatic aortic injury. J Vasc Surg 2023:S0741-5214(23)00280-X. [PMID: 36754248 DOI: 10.1016/j.jvs.2023.01.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury. METHODS MEDLINE, EMBASE, and Cochrane databases were interrogated until June 2021. Inclusion criteria were blunt traumatic aortic injury treated with TEVAR and mean follow-up of more than 60 months. A systematic review was conducted and data were pooled using a random effects model of proportions applying the Freeman-Tukey transformation. Late reintervention was the primary outcome. Secondary outcomes were procedure-related complications (endoleak, in-stent thrombosis, occlusion, infolding/collapse, bird-beak, migration, and left arm claudication), overall and aortic-related mortality, and aortic diameter changes. RESULTS Eleven studies with a low quality assessment were included. Four hundred eight patients were collected and the 389 surviving more than 30 days were included. The mean follow-up was 8.2 years (95% confidence interval [CI], 5.7-10.8; I2 = 40.2%). Late reintervention was 2.1% (95% CI, 0.6-3.9; I2 = 0.0%; 11/389 cases) with 0.1% (95% CI, 0.0-1.2; I2 = 0.0%; 3/389) occurring after 5 years. Bird-beak was identified in 38.7% (95% CI, 16.4-63.6; I2 = 86.6%). Left arm claudication occurring after 30 days was 3.1% (95% CI, 0.1-8.6; I2 = 26.9%; 11/140 cases). In-stent thrombosis was 1.9% (95% CI, 0.1-5.2; I2 = 51.8%; 11/389 cases). Endoleak was 0.5% (95% CI, 0.0-1.9; I2 = 0.0%; 5/389 cases). Infolding, occlusion, and migration were reported in 2 of 389, 1 of 389, and 0 of 389 patients, respectively. Overall late survival was 95.6% (95% CI, 88.1-99.8; I2 = 84.7%; 358/389 patients) and only one patient accounted for aortic related mortality. The increase in proximal and distal aortic diameters was estimated at 2.7 mm (95% CI, 1.2-4.3; I2 = 0.0%) and 2.5 mm (95% CI, 1.1-3.9; I2 = 0.0%), respectively. CONCLUSIONS TEVAR demonstrates remarkably good long-term results and reinterventions are rarely required. Aortic reinterventions tend to occur within the first and after the fifth year.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Luca Mezzetto
- Vascular Surgery, University Hospital of Verona, Verona, Italy
| | | | - Daniele Santi
- Unit of Endocrinology, Department of Medical Specialties, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giorgia Spaggiari
- Unit of Endocrinology, Department of Medical Specialties, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Timothy Resch
- Department of Vascular Surgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Sun J, Ren K, Zhang L, Xue C, Duan W, Liu J, Cong R. Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis. J Cardiothorac Surg 2022; 17:335. [PMID: 36564841 PMCID: PMC9783465 DOI: 10.1186/s13019-022-02094-0] [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: 06/27/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Approximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment. This study analyzed and reported the treatment strategy of a single center for BTAI in the last 10 years and the early and middle clinical results. METHODS This retrospective study included patients diagnosed with BTAI at Xijing Hospital from 2013 to 2022. All inpatients with BTAI aged ≥ 18 years were included in this study. The clinical data, imaging findings, and follow-up results were retrospectively collected and analyzed. The Kaplan-Meier curve and multivariate logistic regression were used to compare survivors and nonsurvivors. RESULTS A total of 72 patients (57% men) were diagnosed with BTAI, with a mean age of 54.2 ± 9.1 years. The injury severity score was 24.3 ± 18, with Grade I BTAI1 (1.4%), Grade II 17 (23.6%), Grade III 52 (72.2%), and Grade IV 2 (2.8%) aortic injuries. Traffic accidents were the main cause of BTAI in 32 patients (44.4%). Most patients had trauma, 37 had rib fractures (51.4%), Sixty patients (83.3%) underwent thoracic endovascular aortic repair (TEVAR) surgery, eight (11.1%) underwent conservative treatment, and only four (5.6%) underwent open surgery. The overall hospitalization mortality was 12.5%. In multivariate logistic regression, elevated creatinine levels (P = 0.041) and high Glasgow coma scale (GCS) score (P = 0.004) were the predictors of hospital mortality. The median follow-up period was 57 (28-87) months. During the follow-up period, all-cause mortality was 5.6% and no aortic-related deaths were reported. Three patients (4.2%) needed secondary surgery and two of them underwent endovascular repair. CONCLUSION Although TEVAR surgery may be associated with intra- or postoperative dissection rupture or serious complications in the treatment of Grade III BTAI, the incidence rate was only 8.9%. Nevertheless, TEVAR surgery remains a safe and feasible approach for the treatment of Grade II or III BTAI, and surgical treatment should be considered first,. A high GCS score and elevated creatinine levels in the emergency department were closely associated with hospital mortality. Younger patients need long-term follow-up after TEVAR.
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Affiliation(s)
- Jingwei Sun
- grid.508540.c0000 0004 4914 235XXi’an Medical University, Xi’an, China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Kai Ren
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Liyun Zhang
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Chao Xue
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Weixun Duan
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, The First Affiliated Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Jincheng Liu
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China ,grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, The First Affiliated Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
| | - Ren Cong
- grid.233520.50000 0004 1761 4404Department of Cardiovascular Surgery, Xijing Hospital, The Air Force Medical University, Xi’an, 710032 Shaanxi China
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Lei X, Hong Z, Pan W, Xiang J, Luo H. Delayed diagnosis of blunt thoracic aortic injury due to thoracic vertebral fracture: A case report and literature review. Front Surg 2022; 9:980451. [PMID: 36338618 PMCID: PMC9630568 DOI: 10.3389/fsurg.2022.980451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/28/2022] [Indexed: 01/24/2023] Open
Abstract
Blunt vascular injury of the aorta combined with thoracolumbar fracture is rare. Delayed diagnosis may have a catastrophic outcome. We present a case of blunt thoracic aortic injury combined with a vertebral body fracture at T10 after a fall from height in which the diagnosis was delayed. After consultation with the vascular and spinal surgeons, we performed a thoracic endovascular aortic repair. When the patient's condition had stabilized, the fractures were reduced using posterior vertebral instrumentation. Prolonged compression of the thoracic aorta resulted in extensive necrosis of muscle tissues in the right lower leg. Fortunately, clinical and radiological examinations performed 7 months and 1 year later did not reveal any further damage. Cases of thoracic vertebral fracture with concomitant blunt thoracic aortic injury reported in the literature are reviewed. Thoracic endovascular aortic repair is a feasible, safe, and effective minimally invasive treatment for aortic injury when combined with thoracic vertebral fracture.
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Affiliation(s)
- Xinhuan Lei
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Zhenghua Hong
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Weixing Pan
- Department of Radiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Jie Xiang
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China,Correspondence: Jie Xiang Hua Luo
| | - Hua Luo
- Department of Orthopedic, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China,Correspondence: Jie Xiang Hua Luo
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Early Diagnosis and Treatment of Nine Patients with Severe Multiple Injuries Accompanied by Traumatic Aortic Dissection during Emergency Treatment. DISEASE MARKERS 2022; 2022:8241405. [PMID: 35299867 PMCID: PMC8923801 DOI: 10.1155/2022/8241405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/27/2022] [Indexed: 11/18/2022]
Abstract
Objective This study is aimed at investigating the early diagnosis and efficacy of emergency treatments of nine patients with severe multiple injuries accompanied by traumatic aortic dissection (TAD). Methods Patients who sustained severe multiple injuries accompanied by TAD following a car accident (n = 6) and falls from a height (n = 3) were treated in the emergency department of our hospital from October 2017 to July 2021. Data of these patients, including seven men and two women (average age, 53 ± 15.2 years; range, 18–83 years) were analysed retrospectively. Upon hospital arrival, the multidisciplinary treatment (MDT) trauma team, composed of doctors and nurses, immediately performed resuscitation following the Green Channel Consultation and Treatment Process for Severe Multiple Injuries. Life-threatening injuries were managed urgently. Blood tests and blood preparation and bedside B-scan ultrasonography and CT were performed. Aortic computed tomography angiography (CTA) was conducted decisively in patients suspected of TAD so that endovascular graft exclusion (EVGE) with the aortic covered stent can be performed promptly, followed by emergency management, second-stage surgery, and intensive care according to the injury control strategy. Results This study included nine patients suffering from severe multiple injuries accompanied by Stanford type B TAD, with injury severity scores ranging from 35 to 43 points. Six patients underwent EVGE while receiving emergency treatment, whereas two patients who also had intracranial haemorrhage underwent selective EVGE. One case of TAD missed in the emergency department was detected 13 days after hospitalisation; therefore, the patient promptly underwent EVGE. Emergency procedures performed included exploratory laparotomy and splenectomy (n = 2), thoracic closed drainage (n = 5), haemothoracotomy (n = 3), second-stage fracture surgery (n = 4), and tracheotomy (n = 1). Postinjury complications included haemorrhagic shock, coagulation disorders, hyoxaemia, pulmonary infection, renal insufficiency, and hypoproteinaemia; however, all patients recovered after intensive care treatment. Aortic CTA after EVGE revealed the disappearance of the dissection and the resorption of the intermural haematoma. However, varying degrees of stenosis or occlusion were observed in the left subclavian artery. Nine patients with severe multiple injuries were treated satisfactorily by the MDT, without fatalities, and all patients were discharged for rehabilitation. Conclusion In this study, procedures including resuscitation, urgent aortic CTA for definitive diagnosis, prompt EVGE, emergency injury control surgery, second-stage definitive surgery, intensive care treatment, and rehabilitation were rationally performed by the emergency MDT trauma team. Overall, this continuous and seamless process is a key factor for the successful treatment of patients with severe multiple injuries accompanied by TAD.
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Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology 2022; 73:497-507. [DOI: 10.1177/00033197211052131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.
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Affiliation(s)
- Ranjan Dahal
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Alan H. Tyroch
- Department of Surgery, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech HSC, Paul Foster School of Medicine, El Paso, TX, USA
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Li L, Lin LY, Lu YQ. Analysis of imaging characteristics of blunt traumatic aortic dissection: an 8-year experience. World J Emerg Med 2022; 13:361-366. [PMID: 36119775 PMCID: PMC9420656 DOI: 10.5847/wjem.j.1920-8642.2022.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Traumatic aortic dissection (TAD) has a low incidence but extremely high mortality. It always presents atypical clinical manifestations that are easily missed or misdiagnosed. This study mainly aims to describe the imaging characteristics and management of TAD patients. METHODS A retrospective analysis of 27 blunt TAD patients was performed between 2013 and 2020. Demographic features, imaging characteristics, and management were analyzed. RESULTS Twenty-seven patients with type B aortic dissection (age 56.04±16.07 years, 20 men) were included. Aortic intimal tears were mostly initiated from the aortic isthmus. The sizes of the proximal intimal tears in the greater curvature were larger than those in the lesser curvature (1.78±0.56 cm vs. 1.24±0.52 cm, P=0.031). Compared with those in the control group, the maximum diameters of the aortic arch, thoracic aorta, and abdominal aorta in the TAD patients were all significantly widened (all P<0.050). Multivariate logistic regression analysis showed that the maximum diameter of the thoracic aorta was an independent risk factor for TAD, with a predictive value with an area under the receiver operating characteristic curve (AUC) of 0.673. Finally, 26 patients successfully underwent delayed thoracic endovascular aortic repair (TEVAR), and the remaining one patient was treated conservatively. No progression of aortic dissection or death occurred during the six-month follow-up period. CONCLUSIONS In blunt trauma, the aortic isthmus is the most common site of proximal intimal tears. An accurate diagnosis of TAD requires an overall consideration of medical history and imaging characteristics. Delayed TEVAR might be an effective therapeutic option for TAD.
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Affiliation(s)
- Li Li
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
| | - Li-ying Lin
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
| | - Yuan-qiang Lu
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- The Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, Hangzhou 310003, China
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Open repair versus thoracic endovascular aortic repair for treating traumatic aortic injury. Asian J Surg 2021; 45:2224-2230. [PMID: 34836763 DOI: 10.1016/j.asjsur.2021.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/20/2021] [Accepted: 11/19/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Blunt traumatic aortic injury (BTAI) is rare and fatal. Treatment has evolved with advances in imaging and the emergence of thoracic endovascular aortic repair (TEVAR). This study reports a single-center, 5-year experience of TEVAR and open repair for BTAI. METHODS Patients with BTAI treated at a level I trauma center from 2014 to 2019 were retrospectively reviewed with patient charts and successive computed tomography angiography images. Patients were grouped according to treatment modality: open repair, TEVAR, or medical management, chosen based on patients' characteristics and injury severity. Groups were compared in terms of preoperative demographics, injury characteristics, operative variables, short-term, and long-term outcomes. RESULTS Forty-two patients were included in the study: 16 (38%) underwent open repair, 17 (40.4%) underwent TEVAR, seven (16.6%) were managed medically, and two (4.7%) died during triage. The median age was 49 years (interquartile range [IQR], 38-57.5 years), and 92.5% were male; the median Injury Severity Score was 33 (IQR, 29-41). Overall mortality was 7.5%. The median hospital stay was 33 days (IQR, 19.5-58.5). Patients undergoing open repair were significantly younger (43 vs. 55 years; p = 0.002) and had a smaller aortic diameter (22.3 vs. 24.0 mm; p=<0.001) than those undergoing TEVAR. No BTAI-related late mortality or reintervention was observed during follow-ups. CONCLUSION This study demonstrated excellent outcomes with multidisciplinary team efforts and appropriate application of treatment modality. TEVAR is ideal for older or severely injured patients; open repair is an important alternative for young patients or patients with unsuitable aortic anatomy.
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Szpytma MM, Gimpel D, Puckridge P, Crouch G. Emergency thoracic endovascular aortic repair and thoracotomy for evacuation of tension haemothorax secondary to erosive paravertebral abscess. ANZ J Surg 2021; 92:929-931. [PMID: 34553829 DOI: 10.1111/ans.17216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Malgorzata Maggie Szpytma
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Damian Gimpel
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Phillip Puckridge
- Department of Vascular Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Gareth Crouch
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Early Clinical Diagnosis and Treatment of Traumatic Aortic Injury Caused by Thoracic and Abdominal Injuries: A Series of Four Cases with Literature Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9995749. [PMID: 33997053 PMCID: PMC8105108 DOI: 10.1155/2021/9995749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023]
Abstract
Aortic injury, particularly traumatic aortic dissection caused by thoracic and abdominal injuries, is extremely rare. The diagnosis rate of blunt aortic injury caused by chest and abdominal injuries is often low, and its clinical manifestations are atypical. Once missed or misdiagnosed, the consequences are serious. Early diagnosis of traumatic aortic injury in complex thoracic and abdominal injuries is a key factor in reducing the mortality of trauma patients. Among all trauma patients treated in our department from December 2018 to December 2020, we diagnosed four cases of aortic injury, including three cases of aortic dissection and one case of intramural hematoma. Successful surgical treatment and clinical outcome were achieved in all four patients. We found that early diagnosis and surgical treatment can help to reduce the mortality of patients with traumatic aortic injury and improve the prognosis.
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Ho VT, George EL, Rothenberg KA, Lee JT, Garcia-Toca M, Stern JR. Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury. J Vasc Surg 2020; 74:71-78. [PMID: 33348003 DOI: 10.1016/j.jvs.2020.12.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/05/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) is an effective treatment of blunt thoracic aortic injury (BTAI). However, the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications. METHODS The Vascular Quality Initiative registry was queried from 2013 to 2019 to identify patients who had undergone TEVAR for BTAI with or without the administration of intraoperative heparin. Univariate analyses were performed with the Student t test, Fisher exact test, or χ2 test, as appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality. RESULTS A total of 655 patients were included, of whom most had presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) of ≥15 (70.2% vs 90.5%; P < .0001) or major head or neck injury (39.6% vs 62.9%; P < .0001). Patients receiving heparin also had a lower incidence of inpatient death (5.1% vs 12.9%; P < .01). Across all injury grades, heparin use was not associated with the need for intraoperative transfusion or postoperative transfusion or the development of hematoma. In patients with grade III BTAI, the nonuse of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%; P < .05). On multivariable logistic regression analysis for inpatient mortality, intraoperative heparin use (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P < .05) and female gender (OR, 0.11; 95% CI, 0.11-0.86; P < .05) were associated with better survival, even after controlling for head and neck trauma and injury grade. In contrast, increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), postoperative transfusion (OR, 1.06; 95% CI, 1.02-1.11; P < .01), higher ISS (OR, 1.04; 95% CI, 1.01-1.07; P < .05), postoperative dysrhythmia (OR, 4.48; 95% CI, 1.10-18.18; P < .05), and postoperative stroke or transient ischemic attack (OR, 5.54; 95% CI, 1.11-27.67; P < .05) were associated with increased odds of inpatient mortality. CONCLUSIONS Intraoperative heparin use was associated with reduced inpatient mortality for patients undergoing TEVAR for BTAI, including those with major head or neck trauma and high ISSs. Heparin use did not increase the risk of hemorrhagic complications across all injury grades. Also, in patients with grade III BTAI, heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI and should be administered when no specific contraindication exists.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, Calif.
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, Calif
| | - Kara A Rothenberg
- Department of Surgery, University of California at San Francisco East Bay, Oakland, Calif
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, Calif
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, Calif
| | - Jordan R Stern
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, Calif
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Endovascular repair of traumatic aortic isthmic rupture: Early and mid-term results. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:254-259. [PMID: 32862982 DOI: 10.1016/j.jdmv.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/13/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Conventional open repair of a traumatic aortic isthmic rupture is associated with a significantly high mortality and morbidity rates. Thoracic endovascular aortic repair (TEVAR) is currently often performed because it is a less invasive treatment than surgery. The aim of this study was to evaluate short and mid-term results of TEVAR in traumatic aortic isthmic rupture. METHODS This is a retrospective study conducted between 2010 and 2018 including patients who underwent TEVAR for traumatic aortic isthmic rupture. RESULTS Thirty-six consecutive patients were included. All patients had sustained a violent blunt chest trauma after a sudden deceleration with associated injuries. The injury severity score (ISS) was 40 (14-66). All patients were hemodynamically stable at admission. We deployed thoracic aorta stent grafts with a mean diameter of 26mm (18-36). The procedural success rate was 100%. We reported one intra-operative complication which was a distal migration of the graft, managed by an implantation of an aortic extension graft. On the first postoperative day, one patient presented an acute lower limb ischemia, probably due to the surgical femoral access, treated with an embolectomy with a Fogarty catheter with satisfactory results. The mean follow-up was 40.41 months (6.5-96). The mortality and paraplegia rates were 0% at one month and during the follow-up period. We reported a case of kinking of the graft that occurred at 6 months. No cases of endoleak neither re-intervention were reported. CONCLUSION TEVAR is a safe and a reliable method for the treatment of sub-acute traumatic thoracic aortic injuries.
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Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center. Ann Thorac Surg 2020; 110:524-530. [DOI: 10.1016/j.athoracsur.2019.11.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/13/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
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Gao JM, Li H, Wei GB, Liu CP, Du DY, Kong LW, Li CH, Yang J, Yang Q. Blunt Cardiac Injury: A Single-Center 15-Year Experience. Am Surg 2020. [DOI: 10.1177/000313482008600432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition—nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant ( P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A ( P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.
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Affiliation(s)
- Jin-Mou Gao
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Hui Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Gong-Bin Wei
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chao-Pu Liu
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ding-Yuan Du
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ling-Wen Kong
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chang-Hua Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Jun Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Qian Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
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Kim SH, Song S, Cho HS, Park CY. Hybrid Approach for Treatment of Multiple Traumatic Injuries of the Heart, Aorta, and Abdominal Organs. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:372-375. [PMID: 31624716 PMCID: PMC6785166 DOI: 10.5090/kjtcs.2019.52.5.372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/09/2019] [Accepted: 07/16/2019] [Indexed: 11/16/2022]
Abstract
A 55-year-old man was admitted to the trauma center after a car accident. Cardiac tamponade, traumatic aortic injury, and hemoperitoneum were diagnosed by ultrasonography. The trauma surgeon, cardiac surgeon, and interventional radiologist discussed the prioritization of interventions. Multi-detector computed tomography was carried out first to determine the severity and extent of the injuries, followed by exploratory sternotomy to repair a left auricle rupture. A damage control laparotomy was then performed to control mesenteric bleeding. Lastly, a descending thoracic aorta injury was treated by endovascular stenting. These procedures were performed in the hybrid-angio room. The patient was discharged on postoperative day 135, without complications.
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Affiliation(s)
- Seon Hee Kim
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital Trauma Center, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Ho Seong Cho
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Chan Yong Park
- Department of Trauma, Wonkwang University Hospital Trauma Center, Wonkwang University School of Medicine, Iksan, Korea
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Mori S, Ai T, Otomo Y. Atypical profile of aortic injury associated with blunt trauma in the metropolitan area of Japan. Trauma Surg Acute Care Open 2019; 4:e000342. [PMID: 31467987 PMCID: PMC6699723 DOI: 10.1136/tsaco-2019-000342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Aortic injury caused by blunt trauma is a critical medical condition that requires extraordinary caution in the treatment. It is often caused by direct hit and high-speed deceleration in motor vehicle accidents. We reviewed and analysed the cases of aortic injury that referred to our institution located in the midst of the metropolitan area of Tokyo, Japan. Methods We retrospectively reviewed the blunt trauma cases transferred to Tokyo Medical and Dental University Hospital in the past 10 years. All cases with aortic injury were analyzed regardless of the AIS scores. Results: Between 2007 and 2017, a total of 3500 blunt trauma cases were transferred. Nineteen cases showed aortic injuries associated with blunt trauma (Age: 63.5±15.6 y.o.; 15 males). Thirteen patients were injured by fall, four patients were senior pedestrians hit by cars, one was injured while riding a motor bike, and one was hit by a train. A total of 11 cases presented a cardiopulmonary arrest on arrival; 8 severe aortic injuries, 1 cardiac rupture; and 2 multiple injuries. Eight cases were alive on arrival; 3 Stanford type A aortic dissections, 3 Stanford type B aortic dissections, and 2 aortic ruptures. Two cases of Stanford type A dissection underwent emergency repairs, whereas all 3 type B dissections went on a good course with conservative treatment. Conclusions Aortic injury caused by blunt trauma seems to be rare in a metropolitan area in Japan. In addition, the leading cause in our cases was fall, which might be a rare cause of aortic injuries in the other countries. Our observation might be a manifestation of population aging.
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Affiliation(s)
- Shusuke Mori
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiko Ai
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan.,Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan
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Lapchak PA, Boitano PD, Bombien R, Chou D, Knight M, Muehle A, Winkel MT, Khoynezhad A. CNB-001 reduces paraplegia in rabbits following spinal cord ischemia. Neural Regen Res 2019; 14:2192-2198. [PMID: 31397359 PMCID: PMC6788235 DOI: 10.4103/1673-5374.262598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Spinal cord ischemia associated with trauma and surgical procedures including thoraco-abdominal aortic aneurysm repair and thoracic endovascular aortic repair results in devastating clinical deficits in patients. Because spinal cord ischemia is inadequately treated, we studied the effects of [4-((1E)-2-(5-(4-hydroxy-3-methoxystyryl-)-1-phenyl-1H-pyrazoyl-3-yl) vinyl)-2-methoxy-phenol)] (CNB-001), a novel curcumin-based compound, in a rabbit SCI model. CNB-001 is known to inhibit human 5-lipoxygenase and 15-lipoxygenase and reduce the ischemia-induced inflammatory response. Moreover, CNB-001 can reduce the level of oxidative stress markers and potentiate brain-derived neurotrophic factor and brain-derived neurotrophic factor receptor signaling. The Tarlov scale and quantal analysis technique results revealed that CNB-001 administered as an intravenous dose (bolus) 30 minutes prior to spinal cord ischemia improved the behaviors of female New Zealand White rabbits. The improvements were similar to those produced by the uncompetitive N-methyl-D-aspartate receptor antagonist memantine. At 48 hours after aortic occlusion, there was a 42.7% increase (P < 0.05) in tolerated ischemia duration (n = 14) for rabbits treated with CNB-001 (n = 16), and a 72.3% increase for rabbits treated with the positive control memantine (P < 0.05) (n = 23) compared to vehicle-treated ischemic rabbits (n = 22). CNB-001 is a potential important novel treatment for spinal cord ischemia induced by aortic occlusion. All experiments were approved by the CSMC Institutional Animal Care and Use Committee (IACUC #4311) on November 1, 2012.
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Affiliation(s)
| | - Paul D Boitano
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Rene Bombien
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Daisy Chou
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Margot Knight
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Anja Muehle
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Mihaela Te Winkel
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
| | - Ali Khoynezhad
- Department of Surgery, Memorial Care Health System, Long Beach, CA, USA
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