The endovascular repair of blunt traumatic thoracic aortic injury in Asia: A systematic review and meta-analysis

Optimal Sizing of Aortic Stent Graft for Blunt Thoracic Aortic Injury Considering Hypotension-Related Decrease in Aortic Diameter

PURPOSE

To evaluate the optimal sizing of an aortic stent graft in patients with blunt thoracic aortic injury (BTAI), considering the decrease in diameter in hypovolemic status.

MATERIALS AND METHODS

From 2014 to 2020, 25 patients who underwent thoracic endovascular aortic repair (TEVAR) for BTAI were included. Hemodynamic parameters in the emergency room (ER) and just before the main procedure (MP) were collected. The aortic sizes were measured during initial computed tomography (CT) on arrival in the ER, aortography (AG) during TEVAR, and final CT in the outpatient clinic. The appropriateness of the inserted stent graft size was investigated.

RESULTS

The mean values of the final CT/initial CT and final CT/initial AG (proximal descending thoracic aorta [pDTA]) were 113% and 105%, respectively. The final CT/initial CT (pDTA; 122.2% vs 108.8%, p=0.01) and final CT/initial AG (pDTA; 113.4% vs 102.1%, p<0.01) were significantly higher in patients with systolic blood pressure (SBP; MP) ≤90 mm Hg. The final CT/initial CT (pDTA; 120.4% vs 109.0%, p=0.03) and final CT/initial AG (pDTA; 111.4% vs 102.6%, p=0.01) were significantly higher in patients with mean blood pressure (MBP; MP) ≤70 mm Hg. On an average, the inserted stent grafts were oversized by 130% on initial AG. Based on the final CT scan, the inserted stent graft was as large as 122%.

CONCLUSION

In the case of hemodynamic instability with SBP (MP) ≤90 mm Hg or MBP (MP) ≤70 mm Hg, despite adequate resuscitation, an oversized TEVAR stent graft of 130% can reduce the occurrence of endoleak and is sufficiently safe.

CLINICAL IMPACT

Despite sufficient resuscitation, the aorta size measured during TEVAR in patients with hemodynamic instability with systolic BP <90 mmHg and mean BP <70 mmHg may be reduced by more than 15% compared to that in the normal state. In this study, the mean size of the stent grafts were oversized by 130% on initial aortography, but were oversized by 122% based on final CT. When the stent graft was oversized by 130% in TEVAR for hemodynamic unstable patient with BTAI, the patient reached the proper oversizing subsequent to hemodynamic recovery.

Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma?

PURPOSE

Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization.

MATERIALS AND METHODS

From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups.

RESULTS

Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001).

CONCLUSION

An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI.

CLINICAL IMPACT

More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.

Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results

OBJECTIVE

This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up.

METHODS

During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter.

RESULTS

Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up.

CONCLUSIONS

Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital

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.

Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases

Background

Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown.

Objectives

The aim of this study is to describe a specialist trauma center’s experience with endovascular treatment of cases like these.

Methods

This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil).

Results

Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection).

Conclusions

The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.

Grade four blunt traumatic aortic injury with massive haemothorax: Resuscitation considerations during the primary survey

Advanced Trauma Life Support principles prioritise the management of 'breathing' over 'circulation' in an acute trauma primary survey. In a tamponaded thoracic aortic rupture, however, this may lead to fatal haemorrhagic shock. In this case, we discuss the resuscitation and management of a patient with a massive left sided haemothorax secondary to a grade four blunt traumatic aortic injury. A 26-year-old male was involved in a high-speed motor vehicle crash and was hypoxic and hypotensive at the scene. His oxygenation and haemodynamics improved with supplemental oxygen and fluid resuscitation. He had a left intercostal catheter inserted after an urgent thoracic endovascular aortic repair was performed to prevent disruption of the contained haemothorax in the presence of a grade four thoracic aortic injury. It is vital to recognise the potential disruption of a tamponaded blunt traumatic aortic injury during consideration of thoracostomy and chest drain decompression.

Application of rib surface positioning ruler combined with volumetric CT measurement technique in endoscopic minimally invasive thoracic wall fixation surgery

Application value of rib surface positioning ruler combined with volumetric CT measurement in selection of the incision for minimally invasive internal fixation of rib fracture was investigated. A total of 80 patients who received internal fixation of rib fractures in Tianjin Hospital Affiliated to Tianjin University (Tianjin, China) from May 2018 to April 2019 were selected. Patients were treated with the rib surface positioning ruler combined with volumetric CT measurement method (n=42) or traditional positioning method (n=38). The following parameters were compared between the two groups: Preset incision accuracy, operation incision length, operation time, intraoperative bleeding volume, postoperative wound drainage volume and postoperative pain score. Compared with the traditional positioning method, rib surface positioning ruler combined with volumetric CT measurement method can improve preset incision accuracy, reduce operation time, incision length, intraoperative bleeding volume, postoperative wound drainage volume, and postoperative pain score, with statistically significant differences (P<0.05). In conclusion, the application of rib surface positioning ruler combined with volumetric CT measurement technique has obvious effect on the selection of incision for internal fixation of rib fracture, and is an effective method worth promoting.

Current status and research progress of minimally invasive surgery for flail chest

Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.