Thoracic aortic injury in Japan--nationwide retrospective cohort study

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience

OBJECTIVE

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI).

MATERIALS AND METHODS

From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter.

RESULTS

Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed.

CONCLUSIONS

Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta.

CLINICAL IMPACT

This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Japanese Multicenter Research of COVID-19 by Assembling Real-world Data: A Study Protocol

BACKGROUND

Data on the evaluation of the clinical course of coronavirus disease 2019 (COVID-19) and the efficacy of treatments after hospitalization in Japan are limited.

OBJECTIVE

This study aimed to construct a database of confirmed COVID-19 cases in Japan and promptly address unresolved research issues.

METHODS

This multicenter observational study included patients who had a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and were discharged from each participating institution between January 1 and September 31, 2020. We called for participating facilities and research proposals until the end of September 2020. The research steering committee members provided advice to co-investigators on refining their research proposals and analyses. After developing the research proposal, we collected clinical information, facility information, and laboratory data from each participating institution. Clinical information was also obtained from the Diagnosis Procedure Combination (DPC) data using a dedicated software called DPC hash application.

ANALYSIS

We planned to conduct an analysis based on the research proposal. Overall, 66 institutions from Japan announced their participation, and 102 research proposals were selected for the analyses. Research areas from the proposals included epidemiology, pathophysiology, therapeutic agents, ventilator settings, cost-benefit analyses, and prognosis prediction for COVID-19.

CONTRIBUTION AND SIGNIFICANCE TO THE FIELD

We have established an efficient data collection system and clinical research team for COVID-19 infection studies. The results of this study may be utilized in future response strategies for COVID-19.

A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients

BACKGROUND

Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications.

METHODS

We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender.

RESULTS

We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I² = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I² = 52%; P = .03), 0% (95% CI, 0%-2.0%; I² = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I² = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I² = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I² = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I² = 65%; P < .01), 0% (95% CI, 0%-1.8%; I² = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I² = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I² = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (β = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (β = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (β = .54; 95% CI, 0.3-0.90).

CONCLUSIONS

This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

Characteristics, treatments, and outcomes among patients with abdominal aortic injury in Japan: a nationwide cohort study

Background

Abdominal aortic injury (AAI) is a life-threatening condition that occurs in only 0.1% of all trauma admissions. Because of its rarity, the clinical features of AAI remain unclear. We investigated the characteristics, treatments, and clinical outcomes among patients with AAI.

Methods

This retrospective cohort study was performed using the Japanese Diagnosis Procedure Combination database. We identified patients with a confirmed diagnosis of AAI with emergency admission from 1 July 2010 to 31 March 2017. Eligible patients were divided into three groups: those who were treated with no surgery or endovascular treatment (non-repair group), those who underwent surgery without endovascular treatment (open repair group), and those who received endovascular treatment without surgery (endovascular repair group).

Results

A total of 238 patients met the inclusion criteria during the study period. Of these, 191 (80.3%) were allocated to the non-repair group, 20 (8.4%) were allocated to the open repair group, and 27 (11.3%) were allocated to the endovascular repair group. The proportions of patients in the non-repair group from July 2010 to March 2012, April 2012 to March 2014, April 2014 to March 2016, and April 2016 to March 2017 were 93.5%, 75.9%, 80.6%, and 73.2%, respectively. The crude in-hospital mortality rate was 26.2%, 35.0%, and 18.5% in the non-repair, open repair, and endovascular repair group, respectively.

Conclusions

In this cohort, the proportion of non-repair for AAI decreased from 2010 to 2017, whereas the proportion of endovascular repair increased. Younger patients were more likely to undergo open repair, whereas older patients were more likely to undergo endovascular repair.

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

INTRODUCTION

Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address.

METHOD

This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773).

RESULTS

Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100 min (95%CI 63.5-136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure.

CONCLUSION

Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.

Long-term Outcomes of Endovascular and Open Repair for Traumatic Thoracic Aortic Injury

IMPORTANCE

Thoracic endovascular aortic repair (TEVAR) has been adopted rapidly for treating traumatic thoracic aortic injury (TAI). The long-term durability and efficacy remain unknown.

OBJECTIVE

To determine the long-term outcomes of thoracic endovascular aortic repair and those of open repair (OR) for traumatic TAI.

DESIGN, SETTING, PARTICIPANTS

This nationwide cohort study used Taiwan's National Health Insurance Database to evaluate patients with traumatic TAI between January 1, 2004, and December 31, 2013. This single-payer National Health Insurance program covered more than 99.9% of the Taiwanese population. Those who received OR or TEVAR for TAI by propensity score matching were included. Data analysis was conducted in October 2017.

EXPOSURES

Thoracic endovascular aortic repair vs open repair.

MAIN OUTCOMES AND MEASURES

In-hospital outcomes, all-cause mortality, aorta reintervention, and stroke during follow-up.

RESULTS

Of the 287 patients (mean [SD] age, 41.66 [17.98] years; 80.5% male) who received OR or TEVAR for TAI, propensity score matching yielded 100 patients each in the OR and TEVAR groups. After propensity score matching, in-hospital mortality risk was significantly lower in the TEVAR group (9 [9.0%]) than in the OR group (27 [27.0%]; TEVAR vs open repair: odds ratio, 0.27; 95% CI, 0.12-0.60). With a mean (SD) follow-up of 2.80 (2.63) years, the proportion of survivors was 71.9% at 1 year, 70.8% at 2 years, 68.2% at 3 years, and 65.1% at 5 years in the OR group vs 88.9% at 1 year, 88.9% at 2 years, 88.9% at 3 years, and 88.9% at 5 years in the TEVAR group (log-rank test, P < .001). The TEVAR group had only 2 events (2%) of late reintervention and 1 event (1%) of late cerebrovascular accident. The proportion of freedom from reintervention was 100% at 1 year, 100% at 2 years, 100% at 3 years, and 100% at 5 years in the OR group vs 97.4% at 1 year, 97.4% at 2 years, 97.4% at 3 years, and 97.4% at 5 years in the TEVAR group (log-rank test, P = .18).

CONCLUSION AND RELEVANCE

Compared with OR, TEVAR was associated with better long-term outcomes, mainly owing to lower mortality during the perioperative period. In addition, TEVAR was associated with a similar rate of survival and reintervention after hospital discharge.

Validation of the prognostic burn index: a nationwide retrospective study

BACKGROUND

The burn index (BI=full thickness total burn surface area [TBSA]+1/2 partial thickness TBSA) and prognostic burn index (PBI=BI+age) are clinically used particularly in Japan. However, few studies evaluated the validation of PBI with large sample size. We retrospectively investigated the relationships between PBI and mortality among burn patients using data from a nationwide database.

METHODS

Data of all burn patients with burn index ≥1 were extracted from the Japanese Diagnosis Procedure Combination (DPC) inpatient database from 1 July 2010 to 31 March 2013 (17,185 patients in 1044 hospitals). The primary endpoint was all-cause in-hospital mortality.

RESULTS

Overall in-hospital mortality was 5.9% (1011/17,185). Mortality increased significantly as the PBI increased (Mantel-Haenszel trend test, P<0.001). The area under the receiver operating characteristic curve for PBI was 0.90 (95%CI, 0.90-0.91), and a PBI above a threshold of 85 showed the highest association with in-hospital mortality. Logistic regression analysis showed that PBI≥85 (odds ratio (OR), 14.6; 95%CI, 12.1-17.6), inhalation injury with mechanical ventilation (OR, 13.0; 95%CI, 10.8-15.7), Charlson Comorbidity Index≥2 (OR, 1.8; 95%CI, 1.5-2.3), and male gender (OR, 1.5; 95%CI, 1.3-1.8) were significant independent risk factors for death.

CONCLUSIONS

Our study suggested that a PBI above a threshold of 85 was significantly associated with mortality. The PBI and mechanical ventilation were the most significant factors predicting in-hospital mortality, after adjustment for inhalation injury, comorbidity, and gender.

Intravenous immunoglobulin use in septic shock patients after emergency laparotomy

OBJECTIVES

The role of intravenous immunoglobulin (IVIG) as an adjunctive treatment for abdominal sepsis remains controversial.

METHODS

Mechanically ventilated septic shock patients following emergency laparotomy for perforation of the lower intestinal tract were identified in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2013. The effect of IVIG use on 28-day mortality was evaluated using propensity score and instrumental variable analyses.

RESULTS

Eligible patients (n = 4919) treated at 845 hospitals were divided into IVIG (n = 2085) and control (n = 2834) groups. Propensity score matching created a matched cohort of 1081pairs with and without IVIG treatment. Although significant mortality differences existed between the IVIG and control groups in the unmatched analysis (20.6% vs. 18.3%; difference, 2.3%; 95% confidence interval [CI], 0.07-4.5), there were no significant differences in the propensity score-matched analysis (20.4% vs. 19.3%; difference, 1.1%; 95% CI, -2.3-4.5). Analysis employing the pattern of hospital IVIG use as an instrumental variable showed that IVIG use was not associated with reduced mortality (difference -2.5; 95% CI, -6.5-1.6).

CONCLUSIONS

There may be no significant association between IVIG use and mortality in mechanically ventilated septic shock patients after emergency laparotomy.

Use of recombinant human soluble thrombomodulin in patients with sepsis-induced disseminated intravascular coagulation after intestinal perforation

BACKGROUND

Anticoagulant therapy has been evaluated with respect to its potential usefulness in reducing the high mortality rates associated with severe sepsis, including sepsis-induced disseminated intravascular coagulation (DIC) after intestinal perforation. We examined the hypothesis that recombinant human soluble thrombomodulin (rhTM) is effective in the treatment of patients with septic shock with sepsis-induced DIC after laparotomy for intestinal perforation.

METHODS

We performed propensity-score and instrumental variable analyses of the Japanese Diagnosis Procedure Combination in-patient database, a nationwide administrative database. The main outcome was 28-day in-hospital all-cause mortality.

RESULTS

We categorized eligible patients (n = 2202) from 622 hospitals into the rhTM group (n = 726) and control group (n = 1476). Propensity-score matching created 621 matched pairs of patients with and without rhTM. There was neither significant difference in 28-day mortality between the two groups in the unmatched analysis (rhTM vs. control, 25.3 vs. 23.4%, respectively; difference, 1.9%; 95% CI, -1.9 to 5.7) nor in the propensity-score-matched analysis (rhTM vs. control, 26.1 vs. 24.8%, respectively; difference, 1.3%; 95% CI, -3.6 to 6.1). The logistic analysis showed no significant association between the use of rhTM and the mortality in propensity-score-matched patients (OR, 1.1; 95% CI, 0.82-1.4). The instrumental variable analyses, using the hospital rhTM-prescribing proportion as the variable, found that receipt of rhTM was not associated with the reduction in the mortality (risk difference, -6.7%; 95% CI, -16.4 to 3.0).

CONCLUSION

We found no association between administration of rhTM and 28-day mortality in mechanically ventilated patients with septic shock and concurrent DIC after intestinal perforation.