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Nana P, Spanos K, Behrendt CA, Brodis A, Haulon S, Kölbel T. A Systematic Review on Thoracic Endovascular Repair Outcomes in Blunt Thoracic Aortic Injuries. J Endovasc Ther 2024:15266028241233163. [PMID: 38369733 DOI: 10.1177/15266028241233163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
PURPOSE Blunt thoracic aortic injury (BTAI) represents a potentially life-threatening condition and thoracic endovascular aortic repair (TEVAR) is recommended as the first-line treatment (Class I level of evidence C) by the current guidelines. The aim of this systematic review was to determine the perioperative and mid-term follow-up outcomes of patients with BTAI treated with TEVAR. MATERIALS AND METHODS We reviewed the English literature published between 2000 and 2022, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until July 30, 2022. Observational studies and case series, with ≥5 patients, reporting on the perioperative and follow-up outcomes of patients who underwent TEVAR for BTAI were included. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, cerebrovascular morbidity. Secondary outcomes were mortality and re-interventions during the mid-term follow-up. RESULTS From 5201 articles identified by the literature search, 35 eligible studies were included in this review. All studies had a retrospective study design. In total, 991 patients were included. The mean age was 34.5±16.5 years (range=16-89 years). Technical success was 98.0% (odds ratio [OR], 95% confidence interval [CI]=0.98, 0.99, p<0.001, I2=0%). Mortality at 30 days was 5.0% (OR, 95% CI=0.03, 0.06, p<0.001, I2=5.56%). Spinal cord ischemia occurred in 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and stroke rate was 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%). The available follow-up was estimated at 29 months (range=3-119 months) with mortality rate at 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and re-intervention rate at 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=10.5%). CONCLUSION Thoracic endovascular aortic repair showed high technical success and low early cerebrovascular morbidity and mortality rates. In the mid-term follow-up, the estimated mortality and re-intervention rates were also low. Furthermore, higher quality prospective studies are needed. CLINICAL IMPACT Thoracic endovascular aortic repair (TEVAR) is recommended as the first line treatement in patients with blunt thoracic aortic injuries (BTAI). This systematic review of 35 retrospective studies and 991 patients showed high technical success (98.0%) with an associated 30-day mortality at 5.0% and low spinal cord ischemia (1%) and stroke rates (2.0%). Mid-term mortality and re-intervention rates reassure the effectiveness of TEVAR in BTAI cases.
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Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Paris, France
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Christian-Alexander Behrendt
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
| | - Alexandros Brodis
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Paris, France
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, UKE Hamburg, Hamburg, Germany
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Ho XN, Wee IJ, Syn N, Harrison M, Wilson L, Choong AM. The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis. Vascular 2019; 27:213-223. [PMID: 30739602 DOI: 10.1177/1708538119828887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. METHOD This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). RESULTS Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100 min (95%CI 63.5-136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. CONCLUSION Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.
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Affiliation(s)
- Xin Nee Ho
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore
| | - Ian Jy Wee
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore
| | - Michael Harrison
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,4 Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Australia
| | - Lauren Wilson
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,5 School of Medicine, Griffith University, Gold Coast, Australia
| | - Andrew Mtl Choong
- 1 SingVaSC, Singapore Vascular Collaborative, Singapore.,2 Division of Vascular Surgery, National University Heart Centre, Singapore.,6 Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,7 Department of Surgery, National University of Singapore, Singapore
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Morris CS. Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients. J Intensive Care Med 2016. [DOI: 10.1177/088506660201700302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.
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Affiliation(s)
- Christopher S. Morris
- Department of Radiology, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT,
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Trends in trauma surgery: analysis of the American Association for the Surgery of Trauma program 1939-2012. J Trauma Acute Care Surg 2014; 76:672-80; discussion 680-1. [PMID: 24553533 DOI: 10.1097/ta.0000000000000149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major trauma-related clinical and basic science innovations have been presented at American Association for the Surgery of Trauma (AAST) annual meetings since its establishment in 1938. Thus, an analysis of all podium presentations was performed to identify historical and current trends in trauma surgery. METHODS All abstract books of the annual meetings of the AAST from 1939 (first meeting) to 2012 were identified except for 1943 and 1945 (no meeting because of World War II) and 1946 (not found). A master list of abstracts (n = 3,637) was generated in Excel. Abstracts were assigned to 14 different categories, and the percentage of each category was tabulated per year. Trend lines were then generated using a mean of 10 zones. In addition, the year in which major clinical and basic science advancements were first presented was recorded. RESULTS Overall, most (20%) AAST presentations have been related to the resuscitation, shock, infection, inflammation, immunology, endocrinology, and metabolism category. This has been followed by the orthopedic (18%) and the torso (chest and abdomen) trauma categories (15%). The trend for each category over time was identified. Prominent trends included a bell-shaped curve for torso, vascular, and genitourinary injuries; a progressive decrease in orthopedic topics; and an increase in critical care topics since the 1970s and in resuscitation/infection/shock and trauma system presentations since the 1980s. First presentations of key topics were identified (n = 163) and tabulated in a chronological order. CONCLUSION Analysis of all oral AAST presentations identified trends and significant milestones in trauma care and research. In its 75 years of existence, the AAST annual meeting remains the forum in which major developments in trauma care and scientific knowledge are presented and disseminated.
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Management of the Left Subclavian Artery during Endovascular Stent Grafting for Traumatic Aortic Injury – A Systematic Review. Eur J Vasc Endovasc Surg 2011; 41:758-69. [DOI: 10.1016/j.ejvs.2011.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 01/04/2011] [Indexed: 11/19/2022]
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Tefera G. Traumatic thoracic aortic injury and ruptures. J Vasc Surg 2010; 52:41S-4S. [PMID: 20800420 DOI: 10.1016/j.jvs.2010.06.142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 06/21/2010] [Accepted: 06/21/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Girma Tefera
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Karmy-Jones R, Teso D, Jackson N, Ferigno L, Bloch R. Endovascular approach to acute aortic trauma. World J Radiol 2009; 1:50-62. [PMID: 21160721 PMCID: PMC2998886 DOI: 10.4329/wjr.v1.i1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 12/18/2009] [Accepted: 12/21/2009] [Indexed: 02/06/2023] Open
Abstract
Traumatic thoracic aortic injury remains a major cause of death following motor vehicle accidents. Endovascular approaches have begun to supersede open repair, offering the hope of reduced morbidity and mortality. The available endovascular technology is associated with specific anatomic considerations and complications. This paper will review the current status of endovascular management of traumatic thoracic aortic injuries.
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Four-Year Follow-Up of Endograft Repair of Traumatic Aortic Transection in a 10-Year-Old. Vasc Endovascular Surg 2009; 43:597-8. [DOI: 10.1177/1538574409334832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels. ACTA ACUST UNITED AC 2009; 67:660-71. [PMID: 19741416 DOI: 10.1097/ta.0b013e3181b2894c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times. METHODS A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma. RESULTS In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%. CONCLUSION The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.
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Karmy-Jones R, Jackson N, Long W, Simeone A. Current management of traumatic rupture of the descending thoracic aorta. Curr Cardiol Rev 2009; 5:187-95. [PMID: 20676277 PMCID: PMC2822141 DOI: 10.2174/157340309788970324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 01/20/2009] [Accepted: 01/21/2009] [Indexed: 11/22/2022] Open
Abstract
Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.
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Affiliation(s)
- Riyad Karmy-Jones
- Divisions of Thoracic-Vascular and Trauma Surgery, Southwest Washington Medical Center, Vancouver WA, USA
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11
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Angiographic embolization of an expanding breast hematoma after blunt trauma: a novel approach to a rare injury. ACTA ACUST UNITED AC 2009; 67:E14-6. [PMID: 19590299 DOI: 10.1097/ta.0b013e3180485cc4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Abstract
The management of thoracic vascular injury has improved dramatically over the past two decades. The availability of multi-row detector CT has facilitated early diagnosis and incorporation of minimally invasive endograft repair for traumatic aortic injury has improved mortality and paraplegia rates. This review evaluates the available data on stent-graft repair of acute blunt traumatic aortic injury and traumatic great vessel injury with regard to safety and efficacy in comparison with conventional open surgical repair.
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Affiliation(s)
- Eric K Hoffer
- Department of Radiology, Section of Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756, United States.
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13
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Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular Stent-Graft or Open Surgical Repair for Blunt Thoracic Aortic Trauma: Systematic Review. J Vasc Interv Radiol 2008; 19:1153-64. [DOI: 10.1016/j.jvir.2008.05.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 05/10/2008] [Accepted: 05/18/2008] [Indexed: 10/21/2022] Open
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Lin PH, Huynh TT, Kougias P, Wall MJ, Coselli JS, Mattox KL. Endovascular Repair of Traumatic Thoracic Aortic Injuries: A Critical Appraisal. Asian Cardiovasc Thorac Ann 2008; 16:337-45. [DOI: 10.1177/021849230801600419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.
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Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Tam T Huynh
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Panagiotis Kougias
- Division of Vascular Surgery & Endovascular Therapy
- Michael E DeBakey VA Medical Center
| | - Mathew J Wall
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Texas Heart Institute at St. Luke's Episcopal Hospital
| | - Kenneth L Mattox
- Division of Cardiothoracic Surgery Michael E DeBakey Department of Surgery Baylor College of Medicine
- Ben Taub General Hospital Houston, USA
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Methodius-Ngwodo WC, Burkett AB, Kochupura PV, Wellons ED, Fuhrman G, Rosenthal D. The Role of CT Angiography in the Diagnosis of Blunt Traumatic Thoracic Aortic Disruption and Unsuspected Carotid Artery Injury. Am Surg 2008; 74:580-5; discussion 585-6. [DOI: 10.1177/000313480807400703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We have replaced aortography and open thoracic surgery to diagnose and treat blunt traumatic thoracic aortic disruption (TTAD) in favor of CT angiography (CTA) and endovascular repair. The purpose of this study is to review our experience with the management and outcomes of TTAD and associated carotid artery injuries. In January 2003, we initiated a protocol that used CTA to evaluate all patients with suspected TTAD from blunt trauma. When TTAD was diagnosed, patients were managed by endovascular repair using abdominal aortic extension cuffs. Twenty-nine patients with TTAD were managed by endovascular repair. In all patients, abdominal endograft extension cuffs successfully excluded the traumatic disruptions. Six (21%) of these patients had concomitant, unsuspected carotid artery injury diagnosed by CTA. One patient had bilateral carotid artery dissections, sustained irreversible brain injury, and died. Four patients with common carotid dissections were successfully treated by anticoagulation and made uneventful recoveries. One patient with a common carotid–innominate artery dissection and pseudoaneurysm underwent endovascular repair. This study indicates that CTA and endovascular repair provide accurate diagnostic and therapeutic results in the management of blunt TTAD. Furthermore, CTA should include arch and cervical views to detect an unsuspected, concomitant carotid artery injury.
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Affiliation(s)
| | - Allison B. Burkett
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Paul V. Kochupura
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - Eric D. Wellons
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - George Fuhrman
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
| | - David Rosenthal
- From the Departments of Trauma and Vascular Surgery, Atlanta Medical Center, Atlanta, Georgia
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Moainie SL, Neschis DG, Gammie JS, Brown JM, Poston RS, Scalea TM, Griffith BP. Endovascular Stenting for Traumatic Aortic Injury: An Emerging New Standard of Care. Ann Thorac Surg 2008; 85:1625-9; discussion 1629-30. [DOI: 10.1016/j.athoracsur.2008.01.094] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 01/24/2008] [Accepted: 01/28/2008] [Indexed: 11/27/2022]
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Tang GL, Tehrani HY, Usman A, Katariya K, Otero C, Perez E, Eskandari MK. Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: A modern meta-analysis. J Vasc Surg 2008; 47:671-5. [PMID: 17980541 DOI: 10.1016/j.jvs.2007.08.031] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 08/17/2007] [Accepted: 08/18/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Gale L Tang
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Raupach J, Ferko A, Lojik M, Krajina A, Harrer J, Dominik J. Endovascular Treatment of Acute and Chronic Thoracic Aortic Injury. Cardiovasc Intervent Radiol 2007; 30:1117-23. [PMID: 17874164 DOI: 10.1007/s00270-007-9053-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Revised: 01/21/2007] [Accepted: 03/07/2007] [Indexed: 10/22/2022]
Abstract
Our aim is to present midterm results after endovascular repair of acute and chronic blunt aortic injury. Between December 1999 and December 2005, 13 patients were endovascularly treated for blunt aortic injury. Ten patients, 8 men and 2 women, mean age 38.7 years, were treated for acute traumatic injury in the isthmus region of thoracic aorta. Stent-graftings were performed between the fifth hour and the sixth day after injury. Three patients (all males; mean age, 66 years; range, 59-71 years) were treated due to the presence of symptoms of chronic posttraumatic pseudoaneurysm of the thoracic aorta (mean time after injury, 29.4 years, range, 28-32). Fifteen stent-grafts were implanted in 13 patients. In the group with acute aortic injury one patient died due to failure of endovascular technique. Lower leg paraparesis appeared in one patient; the other eight patients were regularly followed up (1-72 months; mean, 35.6 months), without complications. In the group with posttraumatic pseudoaneurysms all three patients are alive. One patient suffered postoperatively from upper arm claudication, which was treated by carotidosubclavian bypass. We conclude that the endoluminal technique can be used successfully in the acute repair of aortic trauma and its consequences. Midterm results are satisfactory, with a low incidence of neurologic complications.
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Affiliation(s)
- Jan Raupach
- Department of Radiology, Charles University and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic.
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Lettinga-van de Poll T, Schurink GWH, De Haan MW, Verbruggen JPAM, Jacobs MJ. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg 2007; 94:525-33. [PMID: 17443851 DOI: 10.1002/bjs.5795] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.
Methods
A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.
Results
A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.
Conclusion
Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.
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Affiliation(s)
- T Lettinga-van de Poll
- Department of Vascular Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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Saratzis NA, Saratzis AN, Melas N, Ginis G, Lioupis A, Lykopoulos D, Lazaridis J, Dimitrios K. Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience. Cardiovasc Intervent Radiol 2007; 30:370-5. [PMID: 17295078 DOI: 10.1007/s00270-006-0186-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. METHODS Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. RESULTS Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8-16 months) follow-up. CONCLUSIONS This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.
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Affiliation(s)
- Nikolaos A Saratzis
- 1st Department of Surgery, Aristotle University, Papageorgiou General Hospital, Thessaloniki, Greece.
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Abstract
Endovascular repair of the traumatically injured thoracic aorta has emerged as an exceptionally promising modality that is typically quicker than open repair, with a reduced risk of paralysis. There are a specific set of anatomic criteria that need to be applied, which can be rapidly assessed by the CT angiogram. The enthusiasm for endovascular repair must be tempered by recognition of the complications and lack of long-term follow-up, particularly in younger patients. Surgeons who are skilled in open aortic repair must not only be involved, but should take on a leadership role during the planning, deployment, and follow-up of these patients. Familiarity with all of the available devices expands treatment options. As more specific devices become available, and more follow-up is accrued, the role of endovascular stents will continue to grow.
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Affiliation(s)
- Riyad Karmy-Jones
- Heart and Vascular Center, Divisions of Cardiac, Vascular and Thoracic Surgery, Southwest Washington Medical Center, SWMC Physicians Pavilion, Suite 300, 200 N.E. Mother Joseph Place, Vancouver, WA 98664, USA.
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23
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Liener UC, Sauerland S, Knöferl MW, Bartl C, Riepl C, Kinzl L, Gebhard F. [Emergency surgery for chest injuries in the multiply injured: a systematic review]. Unfallchirurg 2006; 109:447-52. [PMID: 16773318 DOI: 10.1007/s00113-005-1048-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy. METHODS Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system). RESULTS Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (>1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay. CONCLUSION A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.
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Affiliation(s)
- U C Liener
- Abteilung für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universitätsklinik, Steinhövelstrasse 9, 89075 Ulm.
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Steingruber IE, Czermak BV, Chemelli A, Glodny B, Bonatti J, Jaschke W, Waldenberger P, Rieger M, Neuhauser B. Placement of endovascular stent-grafts for emergency repair of acute traumatic aortic rupture: a single-centre experience. Eur Radiol 2006; 17:1727-37. [PMID: 17115167 DOI: 10.1007/s00330-006-0451-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 08/09/2006] [Accepted: 08/18/2006] [Indexed: 11/27/2022]
Abstract
The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.
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Affiliation(s)
- I E Steingruber
- Department of Radiology, University Hospital Innsbruck, Austria.
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25
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Puapong D, Brown CVR, Katz M, Kasotakis G, Applebaum H, Salim A, Rhee P, Demetriades D. Angiography and the pediatric trauma patient: a 10-year review. J Pediatr Surg 2006; 41:1859-63. [PMID: 17101359 DOI: 10.1016/j.jpedsurg.2006.06.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Although interventional radiology has played an increasing role in the management of adult trauma patients, little has been written regarding its application in the care of the injured child. This study analyzed the indications, results, and complications for angiography in pediatric trauma patients. METHODS A retrospective review of pediatric patients (14 years or younger) admitted to Los Angeles County-University of Southern California Medical Center, Los Angeles, Calif (an urban level I trauma center), over a 10-year period (1993-2003) was performed. Patients who underwent angiography were identified using hospital angiography records, and further information was recorded from the trauma registry and medical records. Variables collected included age, sex, mechanism of injury, and injury severity score (ISS). Angiographic data analyzed included indications, results, therapeutic interventions, and procedure-related complications. RESULTS Twenty-five pediatric trauma patients who underwent angiography were identified (18 boys, 7 girls). The average age was 11 years (range, 1-14 years), with an ISS of 16 +/- 10. Indications for angiography included suspected limb ischemia (n = 9), suspected pelvic (n = 8) or solid organ bleeding (n = 8), suspected aortic injury (n = 6), and expanding hematoma (n = 1). Eleven patients (44%) had an abnormal finding, and 10 of 11 underwent a subsequent therapeutic intervention. There was 1 minor procedure-related complication and no procedure-related mortality. CONCLUSIONS Though used infrequently in pediatric trauma patients, the result of the angiography was abnormal in almost half of the children in this series. An abnormal finding prompted further therapeutic intervention in most cases. Angiography was associated with minimal morbidity and should be considered as a useful and safe adjunct when caring for injured children.
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Affiliation(s)
- Devin Puapong
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90033, USA
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26
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Marcheix B, Dambrin C, Bolduc JP, Arnaud C, Hollington L, Cron C, Mugniot A, Soula P, Bennaceur M, Chabbert V, Otal P, Cérène A, Rousseau H. Endovascular repair of traumatic rupture of the aortic isthmus: Midterm results. J Thorac Cardiovasc Surg 2006; 132:1037-41. [PMID: 17059920 DOI: 10.1016/j.jtcvs.2006.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 06/24/2006] [Accepted: 07/07/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The endovascular management of aortic traumatic ruptures has been proposed as an alternative to classical surgical procedures. The aim of this work was to report the midterm results of the endovascular treatment of traumatic ruptures of the isthmic aorta. METHODS Between January 1996 and July 2005, endovascular repair of blunt traumatic aortic ruptures was performed in 33 patients (mean age, 40 +/- 17 years). The stent grafts used were either Talent Medtronic (n = 27), Gore Excluder (n = 4), or Boston Vanguard (n = 2) grafts. Follow-up was 94.9% complete and averaged 32.4 +/- 28.8 months (maximum, 8 years). RESULTS Stent graft deployment was successful in all cases without need for surgical conversion. Except for one iliac rupture, which was treated with an iliofemoral bypass during the same procedure, there was no major perioperative complication. The early complications consisted of 3 primary endoleaks (1 type I and 2 type IV), 1 transient paraparesis, 1 occlusion of the main left bronchus, 1 thrombosis, and 2 pseudoaneurysms of the brachial artery. All the primary endoleaks healed within the first month. No patient died, and no aortic reinterventions were performed. The midterm complications were a mild circumferential thrombus at the distal part of the stent graft and a fracture of the nitinol stent. Both complications were asymptomatic and were discovered on systematic computed tomographic scan examination. Actuarial freedom from complication at 1 year was 96.1% +/- 3.8% and 85.5% +/- 10.6% at 3 and 5 years, respectively. CONCLUSION This study demonstrates that the endovascular treatment of blunt thoracic aortic traumatisms is a safe and effective therapeutic method without increased midterm morbidity and mortality rates.
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Affiliation(s)
- Bertrand Marcheix
- Department of Thoracic and Cardiovascular Surgery, Rangueil University Hospital, Toulouse, France
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27
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Aidinian G, Karnaze M, Russo EP, Mukherjee D. Endograft repair of traumatic aortic transection in a 10-year-old--a case report. Vasc Endovascular Surg 2006; 40:239-42. [PMID: 16703213 DOI: 10.1177/153857440604000310] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blunt abdominal aortic injury from trauma is extremely rare. It is generally from motor vehicular crashes resulting in dissection, intramural hematoma, or free rupture. Timely recognition and treatment of this injury are essential for a chance for survival. To the authors knowledge, this is the first reported case of successful management of this injury, with use of an intravascular stent-graft, in a child. Although open aortic repair has been the only modality used in children, intravascular stent-graft can be another available option in these injuries.
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Affiliation(s)
- Gilbert Aidinian
- Department of Surgery, Walter Reed Army Medical Center, Washington, DC, USA
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28
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Fang TD, Peterson DA, Kirilcuk NN, Dicker RA, Spain DA, Brundage SI. Endovascular management of a gunshot wound to the thoracic aorta. ACTA ACUST UNITED AC 2006; 60:204-8. [PMID: 16456457 DOI: 10.1097/01.ta.0000196318.23409.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Tony D Fang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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29
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Broux C, Thony F, Chavanon O, Bach V, Hacini R, Sengel C, Blin D, Lavagne P, Girardet P, Jacquot C. Emergency endovascular stent graft repair for acute blunt thoracic aortic injury: a retrospective case control study. Intensive Care Med 2006; 32:770-4. [PMID: 16550373 DOI: 10.1007/s00134-006-0115-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting. DESIGN AND SETTING Retrospective case control study in two surgical intensive care units of a university hospital. PATIENTS 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46+/-18 vs. 35+/-15 years). RESULTS In the surgical group time spent in the operating theater was longer (310+/-130 vs. 140+/-48 min) and blood losses higher (2000+/-1300 vs. no significant bleeding); aortic clamping time was 48+/-20 min. The mortality rate was 15% with ESG (n=2) and 23% with surgery (n=4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups. CONCLUSIONS Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.
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Affiliation(s)
- Christophe Broux
- Surgical Intensive Care Unit, Grenoble University Hospital, 38043, Grenoble, France.
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30
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Vignon P, Martaillé JF, François B, Rambaud G, Gastinne H. Transesophageal echocardiography and therapeutic management of patients sustaining blunt aortic injuries. ACTA ACUST UNITED AC 2005; 58:1150-8. [PMID: 15995462 DOI: 10.1097/01.ta.0000169865.23229.58] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation. METHODS We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up. RESULTS All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4). CONCLUSION Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.
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Affiliation(s)
- Philippe Vignon
- Intensive Care Unit, Dupuytren University Hospital, 87042 Limoges, France.
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31
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Rousseau H, Dambrin C, Marcheix B, Richeux L, Mazerolles M, Cron C, Watkinson A, Mugniot A, Soula P, Chabbert V, Canevet G, Roux D, Massabuau P, Meites G, Tran Van T, Otal P. Acute traumatic aortic rupture: A comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg 2005; 129:1050-5. [PMID: 15867779 DOI: 10.1016/j.jtcvs.2004.12.023] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. METHODS A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. RESULTS In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3. CONCLUSIONS In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.
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MESH Headings
- Accidents, Traffic
- Acute Disease
- Analysis of Variance
- Angiography, Digital Subtraction
- Angioplasty, Balloon/adverse effects
- Angioplasty, Balloon/instrumentation
- Angioplasty, Balloon/methods
- Angioplasty, Balloon/mortality
- Aorta, Thoracic/injuries
- Aortic Rupture/diagnosis
- Aortic Rupture/etiology
- Aortic Rupture/therapy
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/methods
- Blood Vessel Prosthesis Implantation/mortality
- Echocardiography, Transesophageal
- Female
- Follow-Up Studies
- Humans
- Injury Severity Score
- Male
- Patient Selection
- Retrospective Studies
- Stents/adverse effects
- Thoracotomy/adverse effects
- Thoracotomy/instrumentation
- Thoracotomy/methods
- Thoracotomy/mortality
- Time Factors
- Tomography, Spiral Computed
- Treatment Outcome
- Wounds, Nonpenetrating/complications
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Affiliation(s)
- H Rousseau
- Department of Radiology, University Hospital Rangueil, 01 av. J Poulhes, 31403 Toulouse, France.
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32
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Rousseau H, Bolduc JP, Dambrin C, Marcheix B, Canevet G, Otal P. Stent-Graft Repair of Thoracic Aortic Aneurysms. Tech Vasc Interv Radiol 2005; 8:61-72. [PMID: 16098939 DOI: 10.1053/j.tvir.2005.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular treatment of aortic disease has emerged as an alternative mode of treatment that is particularly attractive for patients with severe comorbidities who would not be ideal candidates for open surgery. Actually, short-term morbidity and mortality rates, of large series, compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases. However, although endoluminal interventions are minimally invasive, they are associated with complications, as are surgical methods. In this article, indications, technical aspects, and results of endovascular TAA repairs will be reviewed. We will also examine the advantages and limitations of stent-graft treatment. Finally, we will discuss the management of complications following aortic stent-graft implantation. We intentionally do not cover the topic of thoracic dissection, as it is being covered in another article in this volume.
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Affiliation(s)
- H Rousseau
- Department of Radiology, University Hospital Rangueil, Toulouse, France.
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33
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Singh TM, Hung R, Lebowitz E, Wallbom A, Shaver D, Soria J, Zarins CK. Endovascular Repair of Traumatic Aortic Pseudoaneurysm With Associated Celiacomesenteric Trunk. J Endovasc Ther 2005; 12:138-41. [PMID: 15683266 DOI: 10.1583/04-1390.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To report stent-graft repair of a traumatic aortic pseudoaneurysm in proximity to a celiacomesenteric trunk. CASE REPORT An 18-year-old woman suffered a large gunshot wound to the right flank. At laparotomy, only a large, nonexpanding right retroperitoneal hematoma was found, which was thought to represent significant penetrating trauma to the kidney mass. The patient was monitored in the intensive care unit. One week later, computed tomography revealed a partially infarcted right kidney and a 2.3-cm supraceliac aortic pseudoaneurysm, with adjacent bullet fragments. An angiogram confirmed the pseudoaneurysm and showed it to be 7 mm from the celiacomesenteric trunk. Endovascular repair was undertaken with a 16 x 55-mm AneuRx stent-graft, which was successfully placed across the aortic pseudoaneurysm without covering the celiacomesenteric trunk. Imaging at 12 months revealed no endoleak and full pseudoaneurysm exclusion. CONCLUSIONS This operative approach is appropriate for the individual patient who has suitable anatomy and a clinical course that requires immediate repair of an aortic injury to prevent further complications and delays in ancillary treatments.
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Affiliation(s)
- Tej M Singh
- Division of Vascular and Endovascular Surgery, Sant Clara Valley Medicl Center, San Jose, CA 95128, USA.
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34
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Raghavendran K, Singh G, Arnoldo B, Flynn WJ. Delayed Development of Infrarenal Abdominal Aortic Pseudoaneurysm After Blunt Trauma: A Case Report and Review of the Literature. ACTA ACUST UNITED AC 2004; 57:1111-4. [PMID: 15580042 DOI: 10.1097/01.ta.0000053399.86908.11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
MESH Headings
- Accidents, Traffic
- Adult
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/etiology
- Aneurysm, False/surgery
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/etiology
- Aortic Aneurysm, Abdominal/surgery
- Glasgow Coma Scale
- Humans
- Male
- Time Factors
- Tomography, X-Ray Computed
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- Krishnan Raghavendran
- Department of Surgery, Division of Trauma and Critical Care, State University of New York at Buffalo, Buffalo, New York 14215, USA.
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35
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Losanoff JE, Richman BW, Amiridze N, Rider KD, Jones JW. Floating Thrombus of the Thoracic Aorta: A Rare Consequence of Blunt Trauma. ACTA ACUST UNITED AC 2004; 57:892-4. [PMID: 15514551 DOI: 10.1097/01.ta.0000046264.14796.14] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Julian E Losanoff
- Department of Surgery, University of Missouri-Columbia, School of Medicine, Columbia, Missouri 65212, USA
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36
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Stahlfeld KR, Mitchell J, Sherman H. Endovascular Repair of Blunt Abdominal Aortic Injury: Case Report. ACTA ACUST UNITED AC 2004; 57:638-41. [PMID: 15454816 DOI: 10.1097/01.ta.0000042018.39379.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kurt R Stahlfeld
- Department of Surgery, Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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37
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Dunham MB, Zygun D, Petrasek P, Kortbeek JB, Karmy-Jones R, Moore RD. Endovascular stent grafts for acute blunt aortic injury. ACTA ACUST UNITED AC 2004; 56:1173-8. [PMID: 15211121 DOI: 10.1097/01.ta.0000123039.92225.e5] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular stent grafting (EVSG) has emerged as a new treatment for aortic disease and has recently been applied to the treatment of acute blunt aortic injury (BAI). The purpose of this study was to determine the outcome of EVSG for patients with BAI at two tertiary (Level I) trauma centers. METHODS A retrospective review of patients treated between January 1, 1999, and February 1, 2003, at two centers, Calgary Health Region (Calgary, Alberta) and Harborview Medical Center (Seattle, WA), with EVSG for acute BAI is reported. Variables assessed included age, sex, Injury Severity Score, total length of stay (LOS), intensive care unit LOS, operative technique, complications, technical success, mortality, and follow-up data. RESULTS Twenty-eight patients treated with EVSG for BAI were identified during this period. Twelve patients were excluded because injuries occurred more than 30 days before grafting (n = 7) or under a different protocol (n = 4), or the procedure was performed in a different center (n = 1). Sixteen patients with acute BAI were reviewed. The mean Injury Severity Score was 36.9 (SD, 17.0), with a median intensive care unit LOS of 7.5 days (interquartile range, 1-17 days) and total LOS of 24.5 days (interquartile range, 7-41 days). Mean follow-up was 10.7 months (range, 3-30 months). Technical success was achieved in all patients, no graft-related complications have been detected during follow-up, and no patient developed postoperative paraplegia. One postoperative mortality occurred secondary to severe comorbid injury. A single patient with a preoperative traumatic carotid dissection demonstrated a postoperative stroke, and one patient required thoracentesis for a pleural effusion. CONCLUSION Repair of BAI with EVSG can be performed safely in patients with BAI. Mortality, morbidity, and especially paraplegia are reduced. Further long-term studies are required to support the routine use of EVSG technology for BAI.
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Affiliation(s)
- M B Dunham
- Departments of Surgery and Critical Care at the Calgary Health Region, Calgary, Alberta, Canada, and Harborview Medical Center, Seattle, Washington, USA
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Affiliation(s)
- Riyad Karmy-Jones
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of Blunt Thoracic Aortic Injuries: Endovascular Stents versus Open Repair. ACTA ACUST UNITED AC 2004; 56:565-70. [PMID: 15128128 DOI: 10.1097/01.ta.0000114061.69699.a3] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular stent graft (EV) technology has been successfully adapted to the repair of blunt traumatic aortic injuries. The purpose of this study was to compare the outcomes of patients treated with EV repair and open repair after blunt thoracic aortic trauma. METHODS A review of a tertiary trauma center's prospective trauma registry identified all patients who suffered a blunt traumatic thoracic aortic injury over an 11-year period (1991-2002). Operative interventions and outcomes were then compared. RESULTS Over an 11-year period, 18 patients underwent repair of a blunt thoracic aortic injury (EV, 6; open, 12). There were no significant differences in demographics, injury, or crash statistics between groups. The open group had a 17% early mortality rate (n = 2), a paraplegia rate of 16% (n = 2), and an 8.3% incidence of recurrent laryngeal nerve injury (n = 1). This is in contrast to a 0% rate of mortality, paraplegia, and recurrent laryngeal nerve injury in the EV group. A definite trend toward decreased morbidity, mortality, intensive care unit length of stay, and number of ventilator-dependent days was seen with EV repair. CONCLUSION We observed a clear trend toward improved outcomes after EV repair of thoracic aortic injuries compared with standard open repair. EV repair is emerging as the preferred method of repairing blunt thoracic aortic injuries in trauma patients with multiple injuries.
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Affiliation(s)
- Michael C Ott
- Trauma Program, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
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Richeux L, Dambrin C, Marcheix B, Chabbert V, Meites G, Mazerolles M, Mugniot A, Massabuau P, Rousseau H. Vers une nouvelle prise en charge des ruptures traumatiques aiguës de l’isthme aortique. ACTA ACUST UNITED AC 2004; 85:101-6. [PMID: 15094623 DOI: 10.1016/s0221-0363(04)97555-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate the feasibility and safety of endovascular repair in acute traumatic aortic rupture on the basis of our experience with 16 patients. MATERIALS AND METHODS From January 1996 to December 2001,16 patients, with a mean age 36 years, underwent repair of traumatic rupture of the aorta with the use of stent-grafts. All patients presented with coexisting injuries and 9 of 16 patients were hemodynamically unstable because of other injury. After a delay ranging from 9 to 245 days (mean 78 days), aortic stent-grafting was performed by a multidisciplinary team. All patients had regular follow-up with spiral CT and transesophageal echocardiogram. RESULTS Stent-graft placement was successful in all patients with exclusion of false aneurysm. The duration of the procedure was about 120 min and mechanical respiratory assistance could be removed immediately in 80% of patients. Mean stay in the intensive care unit was 24 hours. One complication was noted: compression of the left main stem bronchus successfully treated with endoprosthesis. Maximum follow-up was 7 years. CONCLUSION Endovascular stent-graft repair is a valuable technique and is emerging as an alternative technique for treating thoracic aortic injury in patients in whom coexisting injury increases the surgical risk.
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Affiliation(s)
- L Richeux
- CHU de Rangueil, avenue JeanPoulhès, 31403 Toulouse.
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Karmy-Jones R, Hoffer E, Meissner MH, Nicholls S, Mattos M. Endovascular Stent Grafts and Aortic Rupture: A Case Series. ACTA ACUST UNITED AC 2003; 55:805-10. [PMID: 14608148 DOI: 10.1097/01.ta.0000094429.98136.29] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular stent grafts (EVSGs) offer an alternative in the management of traumatic rupture of the aorta, particularly in patients who are at prohibitive operative risk. METHODS We conducted a retrospective review of 11 cases managed by EVSGs over a 4-year period. EVSGs were defined as "noncommercial" (graft material hand sewn over metallic stents) or "commercial" (grafts marketed for infrarenal aortic or thoracic aneurysms). Data collected included the difference between endovascular stent graft length, tear length (apposition length), and location relative to the left subclavian artery. RESULTS EVSGs (three noncommercial and eight commercial, including AneuRx cuff [six], Talent [one], and Ancure aortic tube graft [one]) were used in 11 patients. Six were placed less than or equal to 8 hours from injury, one after 14 hours, three after 5 days, and one 10 years after injury. Routes of access included femoral (four), iliac (three), and abdominal aorta (four). Average landing zone diameter was 18.8 +/- 3.5 mm, distance from the left subclavian artery was 2.85 +/- 2.1 cm, and tear length was 1.54 +/- 1.0 cm. In four cases, the apposition length was less than 2 cm. There were two cases of persistent endoleak and two cases of endoleak noted and treated at deployment. Persistent endoleak occurred in two of three noncommercial EVSGs. Endoleak occurred in three of four cases when apposition length was less than 2 cm, one of which was treated successfully at the time of placement by deploying extension grafts. Endoleak occurred in two of six cases when deployment was within 2 cm of the origin of the left subclavian artery. In one case of persistent endoleak, open repair was performed 3 weeks later when the patient had stabilized. Ultimately, there were three deaths, two caused by severe closed head injury and one caused by respiratory failure. CONCLUSION Endovascular stent grafts can be placed emergently. Commercial grafts result in better results than noncommercial grafts. Available "cuff extenders" are sufficient for the majority of aortic injuries but often require deployment via the iliac or aorta because of the shorter delivery system. Tears more than 1.5 cm resulting in apposition length less than 2 cm or those near or in the curvature of the aorta are associated with increased endoleak risk. The ideal thoracic EVSG would be available in 5-, 7.5-, 10-, and 15-cm lengths and mounted on a system 80 cm in length.
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Affiliation(s)
- Riyad Karmy-Jones
- Division of Cardiothoracic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Haan J, Rodriguez A, Chiu W, Boswell S, Scott J, Scalea T. Operative Management and Outcome of Iliac Vessel Injury: A Ten-Year Experience. Am Surg 2003. [DOI: 10.1177/000313480306900708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The purpose of this study is to review demographics and examine and stratify risk factors related to the outcome of operatively treated iliac vascular injuries. We conducted a retrospective review of 78 cases of iliac vessel injury. Patients with blunt and penetrating injury had statistically similar length of hospital stay and intensive care unit stay, incidence of shock, and mortality. Shock on admission and bleeding hematoma are linked, and shock increased mortality with an odds ratio of 5.2 ( P = 0.002). A review of operative technique and outcome demonstrated a low mortality of 25 per cent in arterial bypass of an isolated arterial injury versus a mortality of 83 per cent in the combined injury group. Patients treated with primary repair of venous injuries had a lower incidence of shock and mortality compared with patients treated with venous ligation. We conclude that, if matched for severity of injury and physiologic instability, the mechanism of injury does not affect mortality. Shock is the most significant prognostic factor for mortality. Operative management must be based on presence of shock.
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Affiliation(s)
- James Haan
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aurelio Rodriguez
- Shock Trauma Center, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - William Chiu
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sharon Boswell
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jane Scott
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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Lamme B, de Jonge ICDYM, Reekers JA, de Mol BAJM, Balm R. Endovascular treatment of thoracic aortic pathology: feasibility and mid-term results. Eur J Vasc Endovasc Surg 2003; 25:532-9. [PMID: 12787695 DOI: 10.1053/ejvs.2002.1852] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE to report our experience with 21 consecutive patients treated with a thoracic stent-graft. DESIGN retrospective analysis. MATERIALS AND METHODS Between October 1998 and February 2002, 21 patients (12 male), mean age 55.6 years (range 19-86 years), were treated for aorticortic pathology localized to the descending aorta (18 patients), the aortic arch (2 patients) and the ascending aorta (1 patient) and comprising true aneurysms (8 patients), false aneurysms (6 patients), traumatic rupture (4 patients), mycotic aneurysms (2 patients), and ruptured aneurysm (1 patient). Plain chest X-rays and computed tomography was performed at 3, 6 and 12 months postoperatively and then annually. RESULTS the median (range) operation time was 85min (50-305min), hospital stay 6 days (3-63 days) and follow-up 24 months (5-44 months). Complications occurred in 5 patients and comprised intraoperative migration (1), type I endoleak (1), type II endoleak (1), ischemic myelopathy (1), pneumonia (2), suture granuloma (1) and common femoral artery dissection (1). CONCLUSIONS stent-grafting can be successfully employed to treat a wide range of thoracic aortic pathologies with a mortality, morbidity and resource utilization that is considerably less than that associated with conventional surgery. However, long term follow-up on safety and efficacy is needed.
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Affiliation(s)
- B Lamme
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Daenen G, Maleux G, Daenens K, Fourneau I, Nevelsteen A. Thoracic aorta endoprosthesis: the final countdown for open surgery after traumatic aortic rupture? Ann Vasc Surg 2003; 17:185-91. [PMID: 12616363 DOI: 10.1007/s10016-001-0217-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
From December 1998 through May 2001, seven patients with thoracic aortic isthmus rupture underwent endovascular stent graft repair. Diagnosis was made by chest X-ray, transesophageal echography, CT scan, and aortography. The endoprosthesis was ordered and/or custom made on an urgent basis. During the delay period blood pressure was kept low and the tear closely monitored by means of transesophageal echography and CT scan. The mean delay period was 94 days: three patients were treated within 24 hr, two patients had their treatment postponed because of multiple organ failure, and two patients were diagnosed late. Complete exclusion of the pseudoaneurysmal sac was successful in all patients. One patient underwent a preliminary carotidosubclavian bypass because of a short proximal neck, one subclavian artery was unintentionally partially covered, and a second one was deliberately overstented. None of these patients developed arm ischemia or claudication. One patient died 3 weeks after the procedure because of the severity of associated lesions and comorbidity. Our preliminary results prove that endografting for aortic isthmic rupture is technically feasible and that it represents a safe and potentially valuable alternative to the mortality and morbidity of open surgery. Further evaluation is needed to assess the full therapeutic potential and determine the mid and long-term follow-up.
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Affiliation(s)
- G Daenen
- Centre Vascular Diseases, University Hospital Gasthuisberg, Leuven, Belgium
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Fabian TC, Croce MA, Minard G, Bee TK, Cagiannos C, Miller PR, Stewart RM, Magnotti LJ, Patton JH. Current issues in trauma. Curr Probl Surg 2002; 39:1160-244. [PMID: 12476229 DOI: 10.1067/msg.2002.128499] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Timothy C Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Kilaru S, Beavers FP, Heller JA, Lee TY, Marsan BU, Kent KC. Endoluminal stent graft repair of traumatic thoracic aortic pseudoaneurysm. Eur J Vasc Endovasc Surg 2002; 24:456-8. [PMID: 12435348 DOI: 10.1053/ejvs.2002.1744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S Kilaru
- Division of Vascular Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York 10021, USA
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Hoffer EK, Karmy-Jones R, Bloch RD, Meissner MH, Borsa JJ, Nicholls SC, So CR. Treatment of acute thoracic aortic injury with commercially available abdominal aortic stent-grafts. J Vasc Interv Radiol 2002; 13:1037-41. [PMID: 12397126 DOI: 10.1016/s1051-0443(07)61870-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Traumatic rupture of the thoracic aorta is a common cause of death after vehicle collisions. Associated injuries are common, and patients with lung injury, cardiac contusion, abdominal bleeding, and head injury comprise a group at high risk for conventional surgical or medical therapy. In this particular population, existing commercially available stent-grafts may provide a life-saving repair option. The Ancure and AneuRx stent-grafts, designed for abdominal aortic aneurysm application, were successfully placed in three patients. Accommodation for the short length of the delivery device was achieved by retroperitoneal iliac artery access. All patients had follow-up computed tomography (CT) without evidence of endoleak and were doing well with respect to their chest trauma after 5-9 months of follow-up.
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Affiliation(s)
- Eric K Hoffer
- Department of Radiology, Section of Interventional Angiography, Harborview Medical Center, 325 9th Avenue, Box 359728, Seattle, Washington 98104, USA.
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Fattori R, Napoli G, Lovato L, Russo V, Pacini D, Pierangeli A, Gavelli G. Indications for, timing of, and results of catheter-based treatment of traumatic injury to the aorta. AJR Am J Roentgenol 2002; 179:603-9. [PMID: 12185027 DOI: 10.2214/ajr.179.3.1790603] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal treatment for and timing of surgery to repair traumatic aortic injury are still controversial. Endovascular treatment is a viable option in patients with both acute and chronic aortic trauma. However, appropriate patient selection criteria, treatment timing, and long-term durability of endovascular repair remain to be defined. We sought to identify appropriate selection criteria and optimal timing of treatment as well as to assess the long-term durability of endovascular repair. SUBJECTS AND METHODS From July 1997 to December 2001, 19 patients with traumatic aortic injury (11 patients with acute and eight with chronic injuries) were selected for endovascular treatment. In all patients, the lesions were sited at the proximal segment of the descending aorta at a distance of 10 +/- 17 mm (mean +/- SD) from the left subclavian artery. Nine of the patients with acute injuries were treated after clinical stabilization of other severe associated lesions, whereas two patients, in whom hemodynamic and imaging findings suggested an impending rupture, received emergency treatment. Single-detector helical CT or MR imaging was used for patient selection and stent-graft customization before treatment and for evaluation of patients during the follow-up period. RESULTS Endovascular stent positioning was successful in all patients. None of the patients developed complications. Aneurysm exclusion and shrinkage were confirmed at followup examinations. A partial covering of the subclavian artery occurred in six patients without interrupting the blood flow. All patients remain asymptomatic after a mean follow-up period of 20 months (range, 1-56 months). CONCLUSION Endovascular repair represents an alternative, minimally invasive treatment, particularly suitable for use in patients with traumatic aortic injuries. The decision of whether to provide immediate emergency treatment or to delay treatment should be based on the lesion characteristics on imaging and clinical findings. The durability of treatment seems to be related to the absence of alteration to the aortic wall at the extremities.
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Affiliation(s)
- Rossella Fattori
- Department of Radiology, Cardiovascular Unit, University Hospital S. Orsola, Via Massarenti, 9, 40138 Bologna, Italy
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