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Hua Z, Zhou B, Xue W, Zhou Z, Shan J, Xia L, Luo Y, Chai Y, Li Z. Evaluating the effectiveness of immediate vs. elective thoracic endovascular aortic repair for blunt thoracic aortic injury. Chin J Traumatol 2024:S1008-1275(24)00084-1. [PMID: 39179447 DOI: 10.1016/j.cjtee.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 06/15/2024] [Accepted: 07/13/2024] [Indexed: 08/26/2024] Open
Abstract
PURPOSE To evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis. METHODS This is a single-center retrospective cohort study. Patients who received TEVAR for BTAI at our institution from October 2016 to September 2023 were divided into 2 categories depending on the injury severity score (ISS) (≤ 25 vs. > 25) and when the TEVAR was performed for BTAI (within 24 h vs. after 24 h), respectively. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography. Patients treated with open repair and non-operative management were excluded. After propensity-score matching for various factors, outcomes during hospitalization and follow-up were compared. These factors included demographics, comorbidities, concomitant injuries, cause and location of aortic injury, Glasgow coma scale score, society for vascular surgery grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission. The comparison was conducted using SPSS 26 software. Continuous variables were presented as either the mean ± standard deviation or median (Q1, Q3), and were compared using either the t-test or the Mann-Whitney U test. Categorical variables were expressed as n (%), and comparisons were made between the 2 groups using the χ2 test or Fisher's exact test. Statistical significance was defined as a 2-sided p < 0.05. RESULTS In total, 110 patients were involved in the study, with 65 (59.1%) patients having ISS scores > 25 and 32 (29.1%) receiving immediate TEVAR. The perioperative overall mortality rate in the group with ISS > 25 was significantly higher than that in the group with ISS ≤ 25 (11 (16.9%) vs. 2 (4.4%), p < 0.001). Upon admission, the elective group exhibited a notably higher Glasgow coma scale score (median (Q1, Q3)) compared to the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039), while the creatinine concentration (median (Q1, Q3)) at admission was significantly higher in the immediate group (90.5 (63.8, 144.0) vs. 71.5 (58.3, 80.8), p = 0.012). The final sample included 52 matched patients. Complications occurred significantly less frequently in the elective group compared to the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Single-factor analysis of variance showed that complications in hospitalized patients were significantly associated with immediate TEVAR as the sole independent risk factor (odds ratio: 9.000, 95% confidence interval: 2.266 - 35.752, p = 0.002). CONCLUSION In this propensity-score matched analysis of patients undergoing TEVAR for BTAI, elective TEVAR was significantly associated with a lower risk of complication rates. In this study using propensity-score matching, patients who underwent elective TEVAR for BTAI had lower complication rates than immediate TEVAR.
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Affiliation(s)
- Zhaohui Hua
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Baoning Zhou
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Wenhao Xue
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Zhibin Zhou
- Department of Vascular Surgery, Nanchang University Second Affiliated Hospital, Nanchang, 330006, China
| | - Jintao Shan
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Lei Xia
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yunpeng Luo
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yiming Chai
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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Song Q, Bao L, Wu X, Liu B, Wang M. Two cases of complex traumatic aortic dissection combined with multiple organ injuries. Chin J Traumatol 2024:S1008-1275(24)00083-X. [PMID: 39147675 DOI: 10.1016/j.cjtee.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 07/01/2024] [Accepted: 07/28/2024] [Indexed: 08/17/2024] Open
Abstract
Traumatic aortic injury (TAI) is an acute, critical, and severe disease, and then combined with multiple organ damage, it is even more dangerous. TAI progresses very rapidly, with a pre-hospital mortality rate of 57% - 80%, and even when arriving at the hospital, more than one-third of the patients die within 4 h, and it is the 2nd leading cause of death in individuals aged 4 - 34 years. In addition, the incidence of TAI combined with injury was 81.4%. Therefore, early diagnosis, expeditious surgery, and timely and effective multidisciplinary cooperation are essential for successful rescue. The authors report 2 patients with acute traumatic aortic dissection combined with multiple organ injuries and treated with emergency endovascular surgery to discuss their clinical characteristics and treatment experience, and to provide experience in the diagnosis and treatment of such patients.
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Affiliation(s)
- Qingpeng Song
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Lili Bao
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Xuejun Wu
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Bingqi Liu
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Maohua Wang
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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Huang JF, Wang CC, Shen SY, Fu CY, Hsu CP, Cheng CT, Liao CA, Kuo LW, Ou Yang CH, Liao CH. Feasibility of non-operative management for patients sustained blunt splenic traumas with concomitant aortic injuries. Eur J Trauma Emerg Surg 2024; 50:809-820. [PMID: 38097784 DOI: 10.1007/s00068-023-02403-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/09/2023] [Indexed: 07/16/2024]
Abstract
PURPOSE This study aimed to elucidate the treatment approach for blunt splenic injuries concurrently involving the aorta. We hypothesized that non-operative management failure rates would be higher in such cases, necessitating increased hemorrhage control surgeries. METHODS Data from the Trauma Quality Improvement Program spanning 2017 to 2019 were utilized. All patients with blunt splenic trauma were considered for inclusion. We conducted comparisons between blunt splenic trauma patients with and without thoracic or abdominal aortic injuries to identify any potential disparities in treatment. RESULTS Among the 32,051 patients with blunt splenic injuries during the study period, 752 (2.3%) sustained concurrent aortic injuries. Following 2:1 propensity score matching, it was determined that the presence of aortic injuries did not significantly affect the utilization of splenic transarterial angioembolization (TAE) (7.2% vs. 8.7%, p = 0.243) or the necessity for splenectomy or splenorrhaphy (15.3% vs. 15.7%, p = 0.853). Moreover, aortic injuries were not a significant factor contributing to TAE failure, regardless of the location or severity of the injury. Patients with simultaneous splenic and aortic injuries required more red blood cell transfusion within first 4 hours (0 ml [0, 900] vs. 0 ml [0, 650], p = 0.001) and exhibited a higher mortality rate (10.6% vs. 7.9%, p = 0.038). CONCLUSION This study demonstrated that patients with concurrent aortic and splenic injuries presented with more severe conditions, higher mortality rates, and extended hospital stays. The presence of aortic injuries did not substantially influence the utilization of TAE or the necessity for splenectomy or splenorrhaphy. Patients of this type can be managed in accordance with current treatment guidelines. Nonetheless, given their less favorable prognosis, they necessitate prompt and proactive intervention.
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Affiliation(s)
- Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chia-Cheng Wang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Shu-Yueh Shen
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan.
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan.
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chien-An Liao
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, Taiwan
- Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, Taiwan
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Garg I, Siembida JM, Hedgire S, Priya S, Nagpal P. Computed Tomography Angiography for Aortic Diseases. Radiol Clin North Am 2024; 62:509-525. [PMID: 38553183 DOI: 10.1016/j.rcl.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jakub M Siembida
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarv Priya
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Prashant Nagpal
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.
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Garg I, Grist TM, Nagpal P. MR Angiography for Aortic Diseases. Magn Reson Imaging Clin N Am 2023; 31:373-394. [PMID: 37414467 DOI: 10.1016/j.mric.2023.05.002] [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: 07/08/2023]
Abstract
Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University Of New Mexico, Albuquerque, NM 87131, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, E3/366 Clinical Science Center 600 Highland Avenue Madison, WI 53792, USA
| | - Prashant Nagpal
- Cardiovascular and Thoracic Radiology, University of Wisconsin School of Medicine and Public Health, E3/366 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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Li M, Yan Y, Wang C, Tu H. Hospital mortality of blunt abdominal aortic injury (BAAI): a systematic review and meta-analysis. World J Emerg Surg 2023; 18:26. [PMID: 36991444 DOI: 10.1186/s13017-023-00492-w] [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: 12/30/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Studies on the mortality of blunt abdominal aortic injury (BAAI) are rare and have yielded inconsistent results. In the present study, we aimed to quantitatively analyse the retrieved data to more accurately determine the hospital mortality of BAAI. METHODS The Excerpta Medica Database, PubMed, Web of Science and Cochrane Library databases were searched to identify relevant publications without date restrictions. The overall hospital mortality (OHM) of BAAI patients was set as the primary outcome measure. English publications with data that met the selection criteria were included. The quality of all included studies was assessed by the Joanna Briggs Institute checklist and the American Agency for Health Care Quality and Research's cross-sectional study quality evaluation items. After data extraction, a meta-analysis of the Freeman-Tukey double arcsine transformation of data was performed using the Metaprop command in Stata 16 software. Heterogeneity was assessed and reported as a percentage using the I2 index value and as a P value using the Cochrane Q test. Various methods were used to determine the sources of heterogeneity and to analyse the sensitivity of the computation model. RESULTS Of the 2147 references screened, 5 studies that involved 1593 patients met the selection criteria and were included. There were no low-quality references after assessment. One study that only included 16 juvenile BAAI patients was excluded from the meta-analysis of the primary outcome measure due to high heterogeneity. Due to the low heterogeneity (I2 = 47.6%, P = 0.126 for Q test) that was observed after using the random effects model, the fixed model was subsequently used to pool the effect sizes of the remaining four studies, thus yielding an OHM of 28.8% [95% confidence interval (CI) 26.5-31.1%]. The stability of the model was verified by sensitivity analysis, and Egger's test (P = 0.339) indicated a low level of publication bias. In addition, we also performed meta-analyses and obtained a pooled hospital mortality of operation (13.5%, 95% CI 8.0-20.0%), a pooled hospital mortality of non-operation (28.4%, 95% CI 25.9-31.0%), and a pooled rate of aortic rupture (12.2%, 95% CI 7.0-18.5%) of BAAI. CONCLUSIONS The present study indicated that BAAI has an OHM of 28.8%, indicating that this disease deserves more attention and research.
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Affiliation(s)
- Mingxuan Li
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, 199 Youanmenwai St, Fengtai District, Beijing, China
| | - Yu Yan
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, 199 Youanmenwai St, Fengtai District, Beijing, China
| | - Chaonan Wang
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haixia Tu
- Department of Vascular Surgery, Beijing Fengtai You'anmen Hospital, 199 Youanmenwai St, Fengtai District, Beijing, China.
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Yau PO, Lewis E, Shah A, Stone ME, McNelis J, Rivera A. Blunt traumatic aortic injury in the elderly population. J Vasc Surg 2023; 77:47-55.e1. [PMID: 35948245 DOI: 10.1016/j.jvs.2022.07.180] [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: 04/13/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.
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Affiliation(s)
- Patricia O Yau
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY.
| | - Erin Lewis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Amit Shah
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Melvin E Stone
- Department of Surgery, Kings County Hospital, State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - John McNelis
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Aksim Rivera
- Division of Vascular Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Al-Thani H, Hakim S, Asim M, Basharat K, El-Menyar A. Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital. Eur J Trauma Emerg Surg 2022; 48:4079-4091. [PMID: 35286404 PMCID: PMC9532277 DOI: 10.1007/s00068-022-01930-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center. METHODS We conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan-Meier curve and Cox regression analysis were performed for the outcome. RESULTS Eighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I-IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I-II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001). CONCLUSIONS BTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.
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Affiliation(s)
- Hassan Al-Thani
- Trauma and Vascular Surgery Section, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Suhail Hakim
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
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Order and timing of surgeries for thoracic trauma with multiple injuries: A case report. Trauma Case Rep 2022; 38:100625. [PMID: 35252527 PMCID: PMC8889233 DOI: 10.1016/j.tcr.2022.100625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/23/2022] Open
Abstract
The timing and order of multiple surgeries for patients with multiple thoracic injuries have not been standardized. A 75-year-old man, who was injured because of a closing elevator door, underwent intubation, bilateral chest drain insertion, and massive blood transfusion due to shock and respiratory distress. Computed tomography showed hemopneumothorax with extravasation, tracheobronchial injury, aortic injury, thoracic vertebral anterior dislocation, and multiple rib fractures. He was hospitalized and underwent embolization on the day of admission. Next, veno-venous extracorporeal membrane oxygenation (VV-ECMO) was conducted to address severe respiratory failure. The most crucial aspect of the management was treating the tracheobronchial injury because weaning the patient off the VV-ECMO depended on the success of the repair. Thus, the tracheobronchial repair was performed 7–10 days after injury. A right intrathoracic hematoma removal was performed on the third day and a thoracic endovascular aortic repair on the fifth day. The tracheobronchial repair was performed on the ninth day followed by the posterior thoracic fusion on the 18th day. The patient was successfully weaned off the VV-ECMO and mechanical ventilation on the 24th and 46th days, respectively. Early surgery is not always ideal when managing thoracic trauma cases involving multiple sites. Rather, the treatment should be individualized, and the essential surgical procedures should be timed appropriately.
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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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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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12
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Antegrade Hybrid Chimney TEVAR Endograft in a Patient with Blunt Aortic Injury: A Challenging Case with Technical Success but Unfavorable Result. Case Rep Vasc Med 2021; 2021:6380428. [PMID: 33954006 PMCID: PMC8057905 DOI: 10.1155/2021/6380428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/03/2020] [Accepted: 03/31/2021] [Indexed: 11/22/2022] Open
Abstract
Thoracic Endovascular Aortic Repair (TEVAR) has modified aortic medicine, particularly in patients with traumatic aortic injury (TAI). Conventional repair of TAI in the aortic arch is technically demanding as it requires cardiopulmonary bypass and deep hypothermic arrest with still a significant number of complications. Despite recent improvements in endovascular techniques, many patients have been excluded from endovascular repair due to unfavorable anatomy. To increase the feasibility of endovascular repair, adjunctive open extra-anatomical bypasses may be required to provide an adequate proximal landing zone. Several methods, for instance, chimney technique, hybrid technique, and fenestrated or branched stent-grafts, have been proposed as options to preserve the supra-aortic branches, each with its own advantages and disadvantages. We herein present a patient with complex anatomical features and blunt aortic injury, who underwent antegrade chimney stent-graft deployment through the ascending aorta, not otherwise amenable to standard retrograde delivery because of severe peripheral artery disease. The remarkable aspect, in this case, is that both stents were placed antegrade, through the ascending aorta.
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Al-Adawi SSH, Naiem A, Abdelhady I, Al-Sukaiti R, Al-Hajeri M, Stephen E, Al-Shamsi S, Al-Wahaibi K. Chronic Blunt Traumatic Thoracic Aortic Injuries: Report of three cases from Oman. Sultan Qaboos Univ Med J 2021; 21:e120-e123. [PMID: 33777433 PMCID: PMC7968914 DOI: 10.18295/squmj.2021.21.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/03/2020] [Accepted: 07/05/2020] [Indexed: 11/20/2022] Open
Abstract
Blunt thoracic aortic injuries are potentially lethal. Those who survive may form an organised haematoma in the periadventitial space resulting in a pseudoaneurysm, which may be identified incidentally decades later. While the role of thoracic endovascular aortic repair (TEVAR) in acute settings has been established, its role in chronic cases is yet to be defined. We report three cases that were diagnosed incidentally six, nine and 18 years after the injury. Two were managed by TEVAR while the third declined intervention and is on annual follow-up. Patients with asymptomatic and stable pseudoaneurysms of the descending thoracic aorta should be offered surveillance versus TEVAR because the risk of rupture is not negligible, whilst taking into account the patient’s level of physical activity. These three cases highlight the importance of early diagnosis of aortic injuries in blunt trauma and its grading.
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Affiliation(s)
- Sara S H Al-Adawi
- Department of General Surgery, Oman Medical Specialty Board, Muscat, Oman
| | - Ahmed Naiem
- Department of Vascular Surgery, McGill University, Montreal, Canada
| | - Ibrahim Abdelhady
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Rashid Al-Sukaiti
- Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Edwin Stephen
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Khalifa Al-Wahaibi
- Department of Vascular Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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14
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Cheng D, McNickle AG, Fraser DR, Carroll JT, Vega JA, Dickhudt T, Bombard J, Kuhls DA, Chestovich PJ. Early Characteristics and Progression of Blunt Traumatic Aortic Injuries at a Single Level I Trauma Center. Vasc Endovascular Surg 2020; 55:105-111. [PMID: 33063647 DOI: 10.1177/1538574420966450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined. METHODS Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups. RESULTS Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01). CONCLUSIONS While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.
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Affiliation(s)
- Daniel Cheng
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | | | - Douglas R Fraser
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Joseph T Carroll
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Jorge A Vega
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Timothy Dickhudt
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Judzia Bombard
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Deborah A Kuhls
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Paul J Chestovich
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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15
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D'Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, Trimarchi S. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:681-696. [PMID: 32964899 DOI: 10.23736/s0021-9509.20.11580-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
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Affiliation(s)
- Ilenia D'Alessio
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Bissacco
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierantonio Rimoldi
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bruno Palmieri
- Department of Cardio-Thoraco-Vascular Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Santi Trimarchi
- Unit of Vascular Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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16
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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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17
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Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med 2020; 59:418-423. [PMID: 32591302 DOI: 10.1016/j.jemermed.2020.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although surface sonography has become an essential diagnostic tool in the evaluation of trauma patients, important limitations of this modality include the evaluation of retroperitoneal hemorrhage and mediastinal pathology, such as blunt traumatic aortic injuries (BTAI). As in other emergency applications where surface sonography can't provide the information needed, focused transesophageal echocardiography (TEE) may represent a valuable diagnostic tool in the evaluation of hemodynamically unstable trauma patients with suspected thoracic pathology such as BTAI. CASE SERIES We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients.
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Affiliation(s)
- Adi Osman
- Department of Emergency and Trauma, Raja Permaisuri Bainun Hospital, Jalan Raja Ashman (Jalan Hospital), Ipoh, Perak, Malaysia
| | - Chan Pei Fong
- Department of Emergency and Trauma, Raja Permaisuri Bainun Hospital, Jalan Raja Ashman (Jalan Hospital), Ipoh, Perak, Malaysia
| | - Shaik Farid Abdull Wahab
- Department of Emergency Medicine, Universiti Sains Malaysia, Kelantan, Malaysia, Jalan Raja Ashman, Ipoh, Perak, Malaysia
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Felipe Teran
- Division of Emergency Ultrasound, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Emergency Ultrasound and Center for Resuscitation Science, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Kim M, Moore JE. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:61-68. [PMID: 32435162 PMCID: PMC7223697 DOI: 10.1007/s40140-020-00374-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose of Review This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury. Recent Findings Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described. Summary Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.
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Affiliation(s)
- Michelle Kim
- 1University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, MD USA
| | - James E Moore
- 2Consultant Anaesthetist, Intensive Care Physician & Director of Trauma Services, Wellington Hospital, Wellington, New Zealand
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19
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Utilization of endovascular and open surgical repair in the United States: A 10-year analysis of the National Trauma Databank (NTDB). Am J Surg 2019; 218:1128-1133. [DOI: 10.1016/j.amjsurg.2019.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/17/2022]
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20
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Tang S, Tang S, Yu L, Zhang Y, Zhou H. Hybrid treatment of an unusual traumatic aortic arch rupture with pseudoaneurysm: a case report. J Cardiothorac Surg 2019; 14:68. [PMID: 30961673 PMCID: PMC6454696 DOI: 10.1186/s13019-019-0896-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/01/2019] [Indexed: 12/03/2022] Open
Abstract
Background Traumatic aortic arch rupture with pseudoaneurysm is a rare high fatal injury. Thoracic endovascular aortic repair(TEVAR) is widely used in the treatment of aortic diseases. However a unified traumatic aortic injury risk stratification tool still lacks. The patients’ disease assessment and operation method still rely on the doctors’ subjective anticipation of disease and surgical results. Case presentation A 31-year-old male presented with chest pain and hoarseness of recent onset. Imageological examination showed aortic rupture with mediastinal pseudoaneurysm in Zone 1. Debranching + TEVAR hybrid operation was considered: Using artificial blood vessels rebuild the arch branches, the covered stent was placed in aortic arch for endovascular repair via femoral artery. The follow-up was good in postoperative 7d, 1 year and > 2 years. Conclusion The traumatic aortic arch rupture with pseudoaneurysm treated by Debranching+TEVAR hybrid operation is feasible. The short-term and medium-term follow-up results are satisfactory. For traumatic aortic arch injury, hybrid operation is recommended to reduce the risk of cardiopulmonary bypass and deep hypothermia circulatory arrest under no open operation conditions or emergency situation.
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Affiliation(s)
- Shoujun Tang
- Cardiovascular Center, Suining Central Hospital, No.127, West Desheng Road, Chuanshan District, Suining, 629000, Sichuan, China
| | - Shengjie Tang
- Cardiovascular Center, Suining Central Hospital, No.127, West Desheng Road, Chuanshan District, Suining, 629000, Sichuan, China
| | - Li Yu
- Department of ECG, Suining Central Hospital, Suining, 629000, China
| | - Yongheng Zhang
- Cardiovascular Center, Suining Central Hospital, No.127, West Desheng Road, Chuanshan District, Suining, 629000, Sichuan, China
| | - Haining Zhou
- Cardiovascular Center, Suining Central Hospital, No.127, West Desheng Road, Chuanshan District, Suining, 629000, Sichuan, China.
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21
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Zong ZW, Wang ZN, Chen SX, Qin H, Zhang LY, Shen Y, Yang L, Du WQ, Chen C, Zhong X, Zhang L, Huo JT, Kuai LP, Shu LX, Du GF, Zhao YF. Chinese expert consensus on echelons treatment of thoracic injury in modern warfare. Mil Med Res 2018; 5:34. [PMID: 30286811 PMCID: PMC6171144 DOI: 10.1186/s40779-018-0181-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023] Open
Abstract
The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China.
| | - Zhi-Nong Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lian-Yang Zhang
- Department of Trauma Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Yue Shen
- Department of Trauma Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Can Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lin Zhang
- Special Clinic Department of Bethune Medical Profession Sergeant School, Shijiazhuang, 050000, China
| | - Jiang-Tao Huo
- Special Clinic Department of Bethune Medical Profession Sergeant School, Shijiazhuang, 050000, China
| | - Li-Ping Kuai
- Institute of Health Service and Medical Information, Academy of Military Medical Sciences of the Chinese PLA, Beijing, 100850, China
| | - Li-Xin Shu
- Department of Pharmacy, Naval Medical University, Shanghai, 200433, China
| | - Guo-Fu Du
- Institute of Health Service and Medical Information, Academy of Military Medical Sciences of the Chinese PLA, Beijing, 100850, China
| | - Yu-Feng Zhao
- Department of Trauma Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
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Chou EL, Twerdahl EH, Eagleton MJ. Endovascular management of penetrating and non-penetrating aortic injury. VASA 2018; 48:23-33. [PMID: 30227809 DOI: 10.1024/0301-1526/a000740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Aortic trauma is a devastating injury often associated with significant polytrauma. Penetrating injury of the aorta is highly lethal and therefore rarely encountered in the hospital setting. The management of blunt trauma of the aorta has changed significantly over the past decade, principally due to improved imaging technology and the development of endovascular therapy. The most common site of injury is the proximal descending thoracic aorta. The degree of aortic wall injury guides the indication for therapy, while a combination of the degree of injury and the extent of co-morbid injuries drives the timing of repair. Lower grade injuries frequently do not require any surgical intervention. Thoracic aortic endograft repair can be performed in a safe, expeditious fashion. Short-term and mid-term outcomes appear excellent, with patient survival based mainly on concomitant traumatic injuries. Long-term outcomes are less well known. Future endeavors will be guided toward gaining a better understanding of the indications for repair and the long-term outcomes for endograft devices designed for this purpose.
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Affiliation(s)
- Elizabeth L Chou
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
| | - Eric H Twerdahl
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
| | - Matthew J Eagleton
- 1 Massachusetts General Hospital, Division of Vascular and Endovascular Surgery, Boston, USA
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23
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Sandhu HK, Leonard SD, Perlick A, Saqib NU, Miller CC, Charlton-Ouw KM, Safi HJ, Azizzadeh A. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg 2018; 67:389-398. [DOI: 10.1016/j.jvs.2017.07.111] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022]
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24
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Weatherspoon K, Gilbertie W, Catanzano T. Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis. Semin Ultrasound CT MR 2017; 38:370-383. [PMID: 28865527 DOI: 10.1053/j.sult.2017.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.
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Affiliation(s)
- Kimberly Weatherspoon
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA.
| | - Wayne Gilbertie
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, Baystate Medical Center-University of Massachusetts, Springfield, MA
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25
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Gombert A, Barbati ME, Storck M, Kotelis D, Keschenau P, Pape HC, Andruszkow H, Lefering R, Hildebrand F, Greiner A, Jacobs MJ, Grommes J. Treatment of blunt thoracic aortic injury in Germany-Assessment of the TraumaRegister DGU®. PLoS One 2017; 12:e0171837. [PMID: 28346475 PMCID: PMC5367684 DOI: 10.1371/journal.pone.0171837] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/26/2017] [Indexed: 12/30/2022] Open
Abstract
Purpose Using the data delivered by the German Trauma Register DGU® from 2002 till 2013, the value of different therapies of blunt thoracic aortic injury (BTAI) in Germany was analyzed. Methods Prospectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries. Results 821 patients suffering from BTAI were identified: 51.6% (424) grade I injury, 35.4% (291) grade II or III injury and 12.9% (106) grade IV injury (77.5% men [44.94 ± 20.6 years]). The main patterns of injury were high- speed accidents and falls (78.0% [n = 640], 21.8% [n = 171] respectively). Significant differences between grade I and grade II/III as well as IV injuries could be assessed for the incidence of cardiopulmonary resuscitation, a Glasgow Coma Scale score below 8 and a systolic blood pressure below 90 mmHg (p-value: <0.001). In the primary admission subgroup, 44.1% (197/447) of the patients received best medical treatment, 55.9% received surgical intervention (250/447): Thereof 37.2% (93/250) received open surgery and 62.8% (147/250) had been treated by endovascular means. Significantly lower 24-h- and in-hospital-mortality rates were encountered after endovascular treatment for all gradings of BTAI (p-value: <0.001). Yet this subgroup of patients showed the lowest incidence of further severe injuries and cardiac arrest. Conclusion Endovascular therapy became the treatment of choice for BTAI in Germany. Patients who have been treated by surgical means showed the highest survival rate, especially endovascular therapy showed a favorable low mortality rate.
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Affiliation(s)
- Alexander Gombert
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Mohammad E Barbati
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Storck
- Klinikum Karlsruhe, Academic Teaching Hospital Univ. Freiburg, Karlsruhe, Germany
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital RWTH Aachen, Aachen, Germany
| | - Hagen Andruszkow
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Frank Hildebrand
- Department of Orthopedic Trauma at Aachen University and Harald Tscherne Laboratory, University Hospital RWTH Aachen, Aachen, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, University Hospital Charité Berlin, Berlin, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Jochen Grommes
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
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26
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Abstract
Damage control is a surgical strategy that has evolved and expanded considerably over the past 25 years. The approach was initially developed as a "bail out" procedure to control bleeding with severe abdominal injuries in the setting of unmitigated hemorrhagic shock. Damage control is now more broadly applied as a comprehensive management plan for the resuscitation and surgical treatment of injured patients with exhausted physiologic and metabolic reserve. This article reviews the most current concepts in damage control that are important and relevant to the practicing pediatric surgeon. It also provides evidence-based recommendations about how damage control principles can be pragmatically applied to severely injured children. This review focuses specifically on the fundamentals of damage control with respect to resuscitation and the operative treatment of children with severe abdominal, thoracic, and extremity injuries.
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Affiliation(s)
- Anthony Tran
- Pediatric Surgery and Injury Prevention Center, Connecticut Children's Medical Center, Hartford, Connecticut 06106
| | - Brendan T Campbell
- Pediatric Surgery and Injury Prevention Center, Connecticut Children's Medical Center, Hartford, Connecticut 06106.
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27
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Cerna M, Kocher M, Thomas RP. Acute aorta, overview of acute CT findings and endovascular treatment options. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:14-23. [PMID: 28115748 DOI: 10.5507/bp.2016.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/28/2016] [Indexed: 01/17/2023] Open
Abstract
Acute aortic pathologies include acute aortic syndrome (aortic dissection, intramural hematoma, penetrating aortic ulcer), impending rupture, aortic aneurysm rupture and aortic trauma. Acute aortic syndrome, aortic aneurysm rupture and aortic trauma are life-threatening conditions requiring prompt diagnosis and treatment. The basic imaging modality for "acute aorta" is CT angiography with typical findings for these aortic pathologies. Based on the CT, it is possible to classify aortic diseases and anatomical classifications are essential for the planning of treatment. Currently, endovascular treatment is the method of choice for acute diseases of the descending thoracic aorta and is increasingly indicated for patients with ruptured abdominal aortic aneurysms.
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Affiliation(s)
- Marie Cerna
- Department of Radiology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic.,Department of Technical Disciplines in Health Care, Faculty of Health Care, University of Presov, Slovak Republic
| | - Martin Kocher
- Department of Radiology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Rohit Philip Thomas
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg, Oldenburg, Germany
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28
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Contemporary management of civilian penetrating cervicothoracic arterial injuries. J Trauma Acute Care Surg 2016; 81:302-6. [DOI: 10.1097/ta.0000000000001103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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