Aortic transection

Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Stent-graft repair for blunt traumatic aortic injury as the new standard of care: is there evidence?

Designed to treat degenerative aneurysms of the thoracic and abdominal aorta, endovascular stent-grafts have been increasingly employed as an off-label emergency treatment for blunt traumatic aortic injury (BTAI). In this review we explore the controversies associated with thoracic endovascular aortic repair (TEVAR) for BTAI. Early versus delayed treatment of aortic injuries is controversial, and stent-graft repair has further confused the issue of timing the repair. The diagnosis and management of minimal aortic injuries remains elusive. We analyze the available literature pertaining to BTAI, including the recent multicenter prospective trial from the American Association for the Surgery of Trauma. The strengths and weaknesses of the stent-grafts currently available for use in the US are examined to provide insight into which graft may be best suited for BTAI at the present time. Also of importance, we offer recommendations regarding clinical situations in which TEVAR should not be the first line therapy for BTAI. We conclude with a discussion of upcoming trials and new devices that will shape the future of endovascular treatment of BTAI.

Review of branch aortic injuries in blunt chest trauma

OBJECTIVES

To review the incidence, mechanisms of injury, diagnosis and treatment of injuries to the major branches of the thoracic aorta within the thoracic cavity following blunt trauma.

METHODS

Medline, Embase and Cochrane were searched using appropriate key word and MeSH headings. Full text articles were retrieved where there was any information relating to the mechanism of injury, incidence of injury, diagnosis, treatment or outcome in patients with injuries to the brachiocephalic, subclavian or carotid arteries within the thoracic cavity following blunt chest trauma.

RESULTS

The reported incidence of these injuries varied widely, most injuries were related to rapid deceleration injuries or falls. Diagnosis depends on a high level of clinic suspicion and appropriate investigations include helical CT scanning and arteriography. Treatment options have expanded in recent years with the use of endovascular stents; however, the optimal treatment remains uncertain.

CONCLUSIONS

Aortic branch injuries must be actively excluded in patients with suspicious mechanisms of injury. Guidelines determining appropriate investigative pathways and methods of treatment should be developed at all trauma centres.

Motor Vehicle Deaths in Hong Kong: Opportunities for Improvement

OBJECTIVE

This study was undertaken to describe the epidemiology of motor vehicle mortality in Hong Kong, and to assess its impact on trauma service delivery.

SETTING

Hong Kong has an area of 1,072 km2 and a population of 6,800,000. There were 500,000 registered vehicles in 2001.

METHODS

All motor vehicle deaths must be reported to the coroner in Hong Kong. A manual retrospective review of all coroner case notes involving motor vehicles for 2001 was performed.

RESULTS

The review identified 165 cases involving 111 male and 54 female patients. Elderly cases were predominant, with 37% of the cases involving individuals older than 60 years. Most of the cases involved pedestrians (59%), and half of these pedestrians had experienced collisions with public light buses and trucks. Alcohol was not commonly involved, and when it was, it was isolated to the group 20 to 40 years of age. Most individuals died of major head injury alone or multiple injuries. There were very few major vessel injuries, and these included 13 aortic transections.

DISCUSSION

Hong Kong has a very low motor vehicle death rate relative to its population (2.4 per 100,000), but the rate is less impressive when it is related to motor vehicle registrations (33 per 100,000 vehicles). The low incidence of motor vehicle trauma has implications for trauma service delivery in terms of trauma expertise and specialization. Despite the low incidence of trauma, there still are opportunities for prevention, especially in relation to elderly pedestrians and public light buses.

Vascular injury in Australia

Vascular injury poses a small but significant challenge in Australian trauma care. Opportunities such as better practice guidelines and minimum standards will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgery in trauma care should optimize outcomes. The authors' vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve vascular trauma outcomes and reduce mortality.