Blunt Thoracic Aortic Injury Research Articles

The evolution of care improves outcome in blunt thoracic aortic injury: A Western Trauma Association multicenter study.

The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular aortic repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between January 1, 2006, and June 30, 2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). Thoracic endovascular aortic repair and open repair groups had similar Injury Severity Scale score, chest Abbreviated Injury Scale score, Trauma and Injury Severity Score, and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}, 19-51]; TEVAR: 46 [IQR, 28-60]; p < 0.007), zone of aortic injury (p < 0.001), and grade of aortic injury (open: 6 [IQR, 4-6]; TEVAR: 2 [IQR, 2-4]; p < 0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%; p = 0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%. The mortality of BTAI continues to decrease. Thoracic endovascular aortic repair, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in computed tomography imaging in follow-up of TEVAR is warranted. Therapeutic/care management, level III.

Heart structure and vascular function in young patients after endovascular repair for blunt thoracic aortic injury

ObjectiveThoracic Endovascular Aortic Repair (TEVAR) currently represents the gold standard of treatment for Blunt Thoracic Aortic Injury (BTAI). Nevertheless, there is an ongoing debate surrounding its safety and efficacy and its subsequent CV effects. The present study is aimed at assessing heart and aortic structure and function after TEVAR in BTAI patientsMethodIn 20 patients (18 men, age 41 ± 14 years) treated with TEVAR (11 Gore-CTAG, 9 Medtronic-Valiant) after BTAI, between 2004–2015, after a median follow-up time of 3 years (range 12–1 years; T1) we evaluated BP, cf-PWV (sphygmocor) and Left Ventricular Mass Index (LVMI) on echocardiography.ResultsAt baseline, all the patients were normotensive; At T1 despite mean normal BP value (131 ± 12/85 ± 10) 11 patients (55%) were hypertensives. Also LVMI (81,84 ± 28,11 g/m2) and PWV (7,58 ± 1,48 m/s) mean values were within the normal range. When patients were divided accordingly to the used graft patients treated with Medtronic-Valiant showed a significantly higher LVMI (97.17 ± 35.78 vs 69.58 ± 11.24 g/m2; p < 0,05) and PWV (7,78 ± 1,74 vs 6,45 ± 1,54 m/s; p < 0,05) compared with those treated with Gore-CTAG. Same figures were founded when patients were divided accordingly to the treating time with those treated more than 3 years before the evaluation that showed higher LVMI (91,16 ± 34,73 vs 70,20 ± 9,44 g/m2; p < 0,01) and PWV (7,50 ± 1,98 vs 6,38 ± 1,04 m/s; p < 0,05).ConclusionsTEVAR for BTAI is associated after some years with the development of hypertension and heart and vascular alterations. The presence of TEVAR modify aortic functional properties and induce in young subject an increase in BP and LVMI probably related to the presence of a rigid aorta.

Open stent graft repair with upper-half Sternotomy for blunt thoracic aortic injury: a case report

BackgroundThoracic endovascular aortic repair is now widely applied to the treatment of blunt aortic injury. However, its long-term outcomes remain unclear. Endoleakage and migration might occur in the long term, especially when younger patients undergo endovascular aortic repair. In open stent grafting, the proximal end of the open stent graft is directly sutured to the native aorta, which may reduce the risk of endoleakage and migration. We applied open stent grafting to the treatment of blunt aortic injury in the subacute phase and herein report the patient’s clinical course.Case PresentationA 20-year-old man with a developmental disorder collided with a steel tower while skiing. He was transferred to our hospital by helicopter. X-ray examination and computed tomography revealed fractures of left humeral head and femoral neck and aortic isthmus dissection. We did not perform an acute-phase operation because of the presence of multiple trauma and instead performed open stent grafting with an upper-half sternotomy 42 days after the injury. He recovered uneventfully without psychological problems other than his preexisting developmental disorder. No endoleakage or aneurysm was observed during an 18-month follow-up period.ConclusionsOpen stent grafting might be an alternative to open surgery and thoracic endovascular aortic repair for blunt chest trauma, although intensive follow-up is needed.

Limited influence of blunt aortic injuries on the outcome of polytraumatized patients: a matched pair analysis.

Traumatic lesions of great vessels such as the aorta are life-threatening injuries. There is limited evidence about the influence of traumatic aortic injuries in multiple trauma patients in particular with regard to posttraumatic complications. The aim of this study was to evaluate the influence of blunt thoracic aortic injuries in multiple trauma patients compared to a multiple trauma cohort without this specific injury. In addition, the safety of Thoracic Endovascular Aortic Repair (TEVAR) in multiple trauma patients was analyzed. A retrospective study was performed. We included all multiple trauma patients (ISS ≥ 16, age > 14years) between 2005 and 2014 with (group BTAI) and without (group nBTAI) blunt traumatic aortic injuries who were treated at our level-1 trauma center. Demographic as well as clinical parameters were analyzed including injury pattern, mechanism of injury, posttraumatic complications such as ARDS, multiple organ dysfunction syndrome (MODS) and others. A matched pair analysis was performed by propensity score matching. In total, 721 patients were enrolled (group BTAI: n = 45; nBTAI: n = 676). In the initial study population, surgical intervention was done in n = 32 (71.1%) patients (TEVAR: n = 25; 78.1%), there was an increased AISChest and overall injury severity in group BTAI with associated significantly more posttraumatic complications in group BTAI. The matched pair analysis consisted of 42 patients per group. Beside an increased ventilation time, no significant differences were evident after the matching process. There was a trend to increased risk for SIRS using binary logistic regression analysis. Multiple trauma patients with blunt thoracic aortic injuries who are treated at a level-1 trauma center show a comparable outcome matched to their counterparts without aortic injuries. Our study confirms that using TEVAR in polytraumatized patients is a safe procedure. In all patients treated with TEVAR, there were no procedure-related complications, especially no neurological deficit.

Endovascular repair of blunt thoracic aortic injury

Abstract Traumatic thoracic aortic injuries are rare in the pediatric population. Most patients sustaining this injury do not survive and succumb at the scene. Associated injuries can complicate the management of the aortic injury. Aortic injuries have traditionally been treated by open repair. In the adult population, endovascular stenting has become the management of choice. The pediatric literature has isolated reports of the use of endovascular stenting in the repair of aortic injuries. We report an 11 year old female with multiple injuries and a grade III thoracic rupture with a pseudoaneurysm successfully managed with endovascular stenting.

Experts' Results in Blunt Thoracic Aortic Injury are Reproducible in Lower Volume Tertiary Institutions. Early and Mid-term Results of an Observational Study

The aim of this study was to evaluate the early and mid-term clinical results, the device performance, and the mid-term re-intervention rates of patients suffering blunt thoracic aortic injury (BTAI) managed by a multidisciplinary team in a low-volume BTAI centre. This was a retrospective observational study in a tertiary hospital setting. From December 2005 to March 2016, all patients over 18 years old admitted with BTAI were included in the study. No exclusion criteria were applied. The study data were collected and analysed retrospectively. Follow-up of survivors included computed tomography imaging 3 and 9 months post-procedure, then annually. Twenty-eight patients were included in the study. Their mean age was 42±16 years and 89% were male. A contained aortic rupture was diagnosed in 20 patients, a Stanford type B dissection in six, and intramural haematoma in two patients. Multidisciplinary evaluations were performed and an intervention was indicated in 25 patients (89%), four of whom died before the intervention. Nineteen patients underwent thoracic endovascular aortic repair of the descending thoracic aorta and two patients underwent a frozen elephant trunk procedure. The procedures were performed 0.7±1.2 days after injury. All procedures were successful. There were no device related complications. The post-operative 30 day mortality was 5%, with one patient dying on the day of operation from other vascular injuries. The 30 day mortality of all patients was 18%. The median mid-term follow-up period was 786 days. All 30 day survivors survived the follow-up period. The mid-term imaging showed stable results in 19 patients. Two patients required frozen elephant trunk procedures after 240 and 681 days and both procedures were successful. In a low volume centre, a multidisciplinary team using a standardised protocol with the endovascular first approach demonstrated excellent outcomes, similar to those of large centres. If the aortic trauma is adequately managed, the patient's outcome is closely related to the additional trauma.

Contemporary Management of Blunt Thoracic Aortic Injury: Results of an EAST, AAST and SVS survey by the Aortic Trauma Foundation

Objective: To determine contemporary management practices for blunt thoracic aortic injury (BTAI) among trauma and vascular surgeons.Methods: A survey of Eastern Association for the Surgery of Trauma, American Association for the Surgery of Trauma and Society of Vascular Surgeons (SVS) membership regarding BTAI care was conducted.Results: 404 respondents included trauma (52.5%), vascular (42.6%) and other specialty providers (4.5%) primarily from North American (90.6%) academic teaching institutions (71.0%) / American College of Surgeons Level I trauma centers (58.9%). Most respondents managed one to fi ve BTAIs annually (71.6%). Preferred diagnostic modality was computed tomographic angiography (CTA) (99.8%), after which respondents stated they preferred to utilize personal knowledge of the literature and experience (50.5%), the SVS guidelines (27.4%) or institution specifi c guidelines (12.8%) to guide subsequent management. Respondents primarily agreed on the treatment of intimal tears (SVS G1) with medical management. For intramural hematoma (SVS G2), management choice was divided between medical 46.6%) and thoracic endovascular aortic repair (TEVAR) (46.3%). Both groups defi ned TEVAR as treatment of choice for hemodynamically stable patients with pseudoaneurysm (SVS G3) (93.5%) and rupture (SVS G4) (82.2%), although a greater number of trauma surgeons preferred open repair (20.4%) than vascular counterparts (4.1%) in stable G4 patients. Preferred medical management goals varied between mean arterial pressure (37.3%) and systolic blood pressure (62.3%) targets. Preferences also varied in adjuncts for open repair (left heart bypass 56.5%; clamp and sew 46.1%; cerebrospinal fl uid (CSF) drainage 48.5%) and TEVAR (percutaneous puncture for arterial access 58.4%; open vascular exposure 65.5%, intravascular ultrasound 36.1%, CSF drainage 28.9%). Outpatient follow-up timing (2 weeks 37.0%, 1 month 37.2%) and initial type (clinical exam 36.6%, CTA 48.3%) also varied.Conclusions: The survey of trauma and vascular surgeons illustrates controversy regarding SVS G2 treatment, surgical adjuncts and follow-up. Additional study is required to identify optimal BTAI management.

Journal of Endovascular Resuscitation and Trauma Management: A Timely Endeavor

It is with great pleasure that the editorial staff of the Journal of Endovascular Resuscitation and Trauma Management (JEVTM) welcomes your review of – and participation in - our exciting new endeavor. This initial release of JEVTM represents the beginning of the first medical journal specifically dedicated to the examination of endovascular applications as tools for resuscitation, hemorrhage control and definitive trauma management. It is an ambitious undertaking, but one who’s time has come. Why is now the right time for the initiation of JEVTM? The answer to this question involves an examination of several key concepts. These include the emergence of new technologies, changing clinical practices and a growing body of multi-disciplinary innovators dedicated to the exploration and study of an expanding set of endovascular capabilities. Emerging Technologies&#x0D; The past several decades have born witness to an evolution in endovascular technologies. While many of these innovations were initially developed with the treatment of atherosclerotic and aneurysmal vascular disease pathologies in mind, the applications for hemorrhage control and vascular injury management were quickly appreciated. Endovascular balloons, known to potentially improve outcomes from ruptured abdominal aortic aneurysms, are now increasingly utilized as tools for bleeding control from non-compressible sites following trauma. Angio-embolization has become a mainstay of treatment capabilities for both pelvic and solid organ injury at most busy trauma centers. Endovascular stent grafts have emerged as the acute treatment of choice for blunt thoracic aortic injuries. Additionally, other endovascular adjuncts, including extra-corporeal membrane oxygenation (ECMO) and intra-aortic balloon pump devices, continue to evolve as tools of modern resuscitation. Initially, many of these advances were achieved using devices that were largely designed for the management of chronic vascular disease. Increasingly, however, devices and capabilities are being engineered to specifically optimize their utilization for victims of trauma and other patients in need of resuscitative salvage. Continued engineering advancements and efforts to define optimal clinical utilization of these devices will require a platform for reporting and critical review. It is our hope that JEVTM will serve as an effective vehicle for this study.Changing Practices&#x0D; With the increasing inclusion of endovascular capabilities in algorithms for hemorrhage control, resuscitation and trauma management other questions regarding practice have emerged. What provider is best suited to employ these technologies? How should they be trained? What expertise is required? The answer to these questions have not been well elucidated, even as the use of endovascular technologies continues to grow. Beyond the type of providers that should be involved, there also remain questions about the optimal care environment in which these technologies should be delivered. Is a hybrid-operating suite the optimal environment? How much imaging capability is really required? Can some of these capabilities safely be brought to the pre-hospital care environment? These questions are matters of active investigation that require a venue like JEVTM for examination.A multi-disciplinary collaboration&#x0D; The foundation for the creation of JEVTM can be traced to discussions that culminated in the February 2017 Endovascular Hybrid and Trauma Management Meeting in Orebro, Sweden. This gathering, sponsored by the University of Orebro, brought together thought leaders from nations throughout Europe, North America and Asia. Their diversity in geographic representation was second only to their diversity of training backgrounds. Interventional radiologists, emergency medicine physicians and surgeons (vascular, trauma and acute care) shared their clinical experiences with not only each other – but also a large group of translational scientists working diligently to provide important foundational data for next steps in endovascular applications. In the context of this excellent exchange, many of these multi-disciplinary participants discussed work that had been presented at prestigious meetings and had been published in a wide array of medical journals scattered across a variety of disciplines. It became apparent, however, that there was a need for a platform that might serve as a common ground for this diverse group of providers striving to advance the safe and effective use of endovascular technologies in resuscitation and trauma management. It is our hope that the Journal of Endovascular Resuscitation and Trauma Management serves as that needed platform.&#x0D;

P5190Endovascular repair for blunt thoracic aortic injury: subsequent heart structure and vascular function

P5190Endovascular repair for blunt thoracic aortic injury: subsequent heart structure and vascular function

PC172 Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Is Not Necessary to Achieve Aortic Healing in Patients With Short Proximal Landing Zones

PC172 Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Is Not Necessary to Achieve Aortic Healing in Patients With Short Proximal Landing Zones

Treatment of blunt thoracic aortic injury in Germany-Assessment of the TraumaRegister DGU®.

PurposeUsing 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.MethodsProspectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries.Results821 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.ConclusionEndovascular 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.

Endovascular treatment of blunt thoracic aortic injuries

A new era has begun in the last two decades with the advent of endovascular methods in the therapy of blunt thoracic aorta injuries. Our experiences with the endovascular interventions of blunt aortic trauma in the Cardiovascular Center of Semmelweis University are summarised here. We included those patients who underwent endovascular intervention due to blunt aortic trauma in a university hospital between 1998 and 2014. The statistical analysis was performed with the use of Excel. 41 patients were selected from our database. There were 34 males, the average age was 47 years (±17 years). Among the 41 patients 15 underwent an acute procedure (12 ruptures) and 26 patients received delayed treatment (in 4 cases due to growing of the pseudoaneurysm). There was only one early postoperative death. Late mortality was 22.5% and 7.5% was related to the aortic injury. Our late mortality and complication rates were similar to other studies, which reinforces international experiences. In the cases when delayed treatment is feasible, the patient can be stabilized and the CTA images can be analyzed for precise stentgraft planning. The treatment of blunt thoracic aorta injured patients should take place in specialized centers capable of such endovascular interventions.

Endovascular repair of a thoracic aortic transection 31 years after blunt trauma

A 46-year-old woman presented with a 3-month history of persistent cough and hoarseness with anterior chest pain. A chest radiograph revealed a large upper lobe mass with obliteration of the left lung field. She soon developed hemoptysis, and computed tomography was performed urgently. This showed a ruptured 13-cm thoracic aortic pseudoaneurysm (A). Further inquiry revealed that she was involved in a severe motor vehicle accident at 15 years of age. She was in a “coma” for many weeks, but the patient did not remember any chest trauma or surgery. The patient was urgently taken to the hybrid operating room. Aortography showed a large pseudoaneurysm distal to the subclavian consistent with previous transection (B/Cover). Through femoral access, two TAG devices (W. L. Gore & Associates, Flagstaff, Ariz) were placed (C). Balloon angioplasty was not performed. The patient was discharged on postoperative day 2 doing well with no neurologic sequelae. At 6-month follow-up, the patient was doing well with resolution of all symptoms. Computed tomography angiography showed no endoleak and the aneurysm sac to measure 9.6 cm in diameter (D). There was re-expansion of the lung field as well. The patient has consented to the publication of this report along with its accompanying operative images. Aortic transection remains one of the leading causes of death during blunt trauma. The majority of victims, up to 75%, die before reaching a care facility.1Estreta A.L. Gochnour D.C. Azizzadeh A. Miller 3rd, C.C. Coogan S. Charlton-Ouw K. et al.Progress in the treatment of blunt thoracic aortic injury: 12 year single-institution experience.Ann Thorac Surg. 2010; 90: 64-71Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Those who do present to the hospital in most cases have multiple other severe injuries. Historically, open repair had high mortality and morbidity rates, up to 50% and 80%, respectivetly.2Klima D.A. Hanna E.M. Christmas A.B. Huynh T.T. Etson K.E. Fair B.A. et al.Endovascular graft repair for blunt traumatic disruption of the thoracic aorta: experience at a nonuniversity hospital.Am Surg. 2013; 79: 594-600PubMed Google Scholar Therefore, thoracic endovascular aortic repair has replaced open repair as the preferred method of treatment at most centers. Studies have shown lower complication rates with excellent technical success rates and long-lasting results with thoracic endovascular aortic repair.3Estrera A.L. Miller 3rd, C.C. Guajardo-Salinas G. Coogan S. Charlton-Ouw K. Safi H.J. et al.Update on blunt thoracic injury: fifteen-year single-institution experience.J Thorac Cardiovasc Surg. 2013; 145: S154-S158Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Recently, it has been shown that surgery can be delayed in selective cases to allow treatment of other injuries and time for the patient's overall condition to improve with continued good outcome.3Estrera A.L. Miller 3rd, C.C. Guajardo-Salinas G. Coogan S. Charlton-Ouw K. Safi H.J. et al.Update on blunt thoracic injury: fifteen-year single-institution experience.J Thorac Cardiovasc Surg. 2013; 145: S154-S158Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In some cases, the transection is missed, with long-term pseudoaneurysm expansion and eventual complications. Here, we presented a case of delayed repair of a transection that occurred >30 years previously with excellent results.

Functional Assessment and Evaluation of Outcome After Endovascular Therapy With Coverage of the Left Subclavian Artery in Case of Blunt Thoracic Aortic Injury

Patients suffering blunt thoracic aortic injury (BTAI) can be treated by use of thoracic endovascular aortic repair (TEVAR). In this setting, the coverage of the left subclavian artery (LSA) is frequently necessary. Nevertheless, the functionality of the upper left extremity after TEVAR had been rarely analyzed. Thus, this study intends to underline the safety of TEVAR as well as to determine the functionality of the left arm after coverage of the LSA. All patients suffering from BTAI treated by endovascular means in 3 centers (Aachen [Germany], Maastricht [Netherlands], and Innsbruck [Austria]) between 1996 and2009 were retrospectively analyzed. The safety of the procedure had been assessedby the morbidity and mortality rate. The mid-term functional status of the upper left extremity was evaluated by using the DASH score (disabilities of the arm shoulder and hand). Forty-six patients (40 male, 6 female), mean age 39.4 ± 16.9years suffered from BTAI caused by traffic accident (n=31 [67.39%]), by skiing injury (n=8 [17.39%]), and by fall (n=7 [15.21%]). All patients underwent TEVAR, the technical success rate was 100%; 1 carotid-carotid subclavian bypass implantation was necessary. LSA coverage was performed in 76% (35/46) of the cases. Total complication rate was 17.3% (8/46); the endoleak rate was 8.6% (4/46) (2 × Ib, 1 × IIa, 1 × IV). Further complications were bypass andendograft occlusion. The postoperative mortality rate was 6% (3/46), the DASH score was completed in 65% (30/46). The study population reached a mean value of 17±20, which is comparable to a nonharmed reference group (10.10±14.68). A significant correlation between the DASH score and patients age could be demonstrated (2-sided P value: 0.0213). Endovascular therapy of BTAI revealed a good primary success rate. An adequate mid-term functional status of the upper left extremity could be assessed in comparison to a nonharmed reference group.

Association between Prehospital Time and Mortality following Blunt Thoracic Aortic Injuries

Blunt thoracic aortic injuries (BTAIs) can be lethal, but advances in trauma systems and surgical care have helped reduce mortality. The purpose of this study is to investigate whether time from injury to presentation is associated with mortality following BTAI. Using the Ontario Trauma Registry, all patients were identified who were hospitalized with BTAI between 1999 and 2009. Variables including age, sex, Injury Severity Score, Charlson comorbidity index, systolic blood pressure on admission, operative intervention, and time from injury to presentation were analyzed using multivariate logistic regression to determine independent predictors of mortality. We identified 264 cases of BTAI that survived until hospital admission. Of these, 220 patients had documented time from injury to presentation to hospital. Most, 68.2% (n=150), presented within 60min of injury. On adjusted multivariate analysis, a prehospital time of ≤60min independently predicted higher mortality (odds ratio 0.27, 95% confidence interval 0.08-0.89, P=0.03). Tight clustering was seen with prehospital time and mortality. Rather than reducing mortality as hypothesized, a shorter time between BTAI and hospital presentation (<60min) is associated with increased mortality. This may be the result of selection bias with the quicker transport of more severely injured patients.

CTA signs for blunt thoracic aortic injury: a review of 37 cases

Objective To review computed tomographic angiography(CTA)signs and its potential use in the diagnose of blunt thoracic aortic injury Methods We reviewed 37 cases with blunt thoracic aortic injury (TAI) confirmed by surgery or aortography in Chinese PLA General Hospital emergency department from June 2004 to June 2014. CTA were performed on these patients, and CTA images were analyzed retrospectively to obtain characteristic CTA signs of blunt thoracic aortic injury. Results Of the 37 cases, the blunt injury in aortic isthmus were 83.8% (31/37), aortic arch 5.4% (2/37), descending aorta 8.1% (3/37), and ascending aorta 2.7% (1/37), respectively. CTA signs of thoracic aortic injury manifested as intimal flap in 34 patients (91.8%), abnormal aortic contour or cavity in 37 cases (100%), arterial contraction in 17 cases (45.9%), aortic dissection in 10 cases (27.0%), pseudoaneurysm in 21 cases (56.7%), thrombosis in 1 case (2.7%). Conclusions CTA signs could be used to facilitate the diagnosis of blunt thoracic aortic injury with a qualitative diagnostic value. Key words: Cases; Blunt trauma; Thoracic; Aorta; Injury; CT; Angiography; Signs Diagnosis

Nonoperative management of grade III blunt thoracic aortic injuries

Blunt thoracic aortic injuries (BTAIs) have historically been treated with open surgery; thoracic endovascular aortic repair (TEVAR), however, is rapidly becoming the standard of care for all grades of injury. Previous studies have shown successful, conservative management of low-grade (I and II) BTAI, but limited literature exists regarding nonoperative management (NOM) for high-grade BTAI. The purpose of this study was to evaluate NOM for grade III BTAI compared with TEVAR. There were 75 patients diagnosed with BTAI between January 2004 and June 2015. Of these, 40 were excluded for different grades of BTAI (17), death before any treatment (6), and need for urgent open repair (17). The remaining 35 patients were divided into two groups by treatment approach: NOM (n= 18) and TEVAR (n= 17). Primary end points were complications and mortality. The secondary end point was difference in pseudoaneurysm and aortic diameter measurements between groups. The groups of patients were similar in age, gender, Injury Severity Score, length of stay, in-hospital mortality, and hospital-associated complications. There were four TEVAR-related complications: graft involutions (2), type I endoleak (1), and distal embolization (1). All TEVAR-related complications required either an adjunctive procedure at the time of the primary procedure or an additional procedure. No patients from the NOM group required operative intervention. There were seven in-hospital mortalities: two in the TEVAR group (11.8%) and five in the NOM group (27.8%; P= .402). One death in the NOM group was related to aortic disease. Follow-up computed tomography imaging revealed similar aortic-related outcomes between groups, with a high proportion showing resolved or improved aortic injury (NOM, 87.5%; TEVAR, 92.9%; P= .674). Initial computed tomography imaging showed similar aortic diameters between groups. The average diameter of the aorta distal to the subclavian artery was 22.6mm in the NOM group vs 22.8mm in the TEVAR group (P= .85). The average maximum diameter of the pseudoaneurysm was 30.1mm in the TEVAR group and 29.9mm in the NOM group (P= .90). The average ratio of diameter of the pseudoaneurysm to diameter of the aorta distal to the subclavian artery was 1.32 for the TEVAR group and 1.33 for the NOM group (P= .85). The natural history of grade III BTAIs is not well described. This study suggests that observation and NOM of grade III BTAI may be a reasonable therapeutic option in selected patients. It also speaks to the need for further delineation of the natural history of this injury. Serial imaging and long-term follow-up are necessary to monitor the progression of the pseudoaneurysm.

Endovascular Repair of Blunt Thoracic Aortic Injuries With the Zenith Alpha Thoracic Device: Updated Outcomes From the TRANSFIX Study

Endovascular Repair of Blunt Thoracic Aortic Injuries With the Zenith Alpha Thoracic Device: Updated Outcomes From the TRANSFIX Study

Differences in Aortic Diameter Measurements With Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury

Background Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) as computed tomography (CT) in injured patients may inaccurately determine the true aortic diameter. We hypothesize that CT and IVUS offer discordant measurements of aortic diameter in trauma patients and that each modality may result in different graft size estimates for TEVAR. Methods Patients treated by TEVAR for blunt aortic injury from June 2011 to 2016 were reviewed. Cases where IVUS was not used and those without complete CT and IVUS images were excluded. Three-dimensional reconstructions were used to derive centerline diameters of the aorta, proximal and distal to the injury. IVUS diameters were taken from the flow lumen, not including the aortic wall itself. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) with patients with discordant diameters (group 2). Results A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (±18), and 12 of the patients were men. The median time from injury to CT was 2.5 hr (0.9–8.5) and to TEVAR was 18 (3–48) hr. Stent graft diameter for implantation based on CT and IVUS imaging was the same in 5 cases (group 1). In 11 cases, the graft diameter for implantation based on IVUS was differently sized compared with that determined by CT (group 2). Ten diameters were 1 size larger, and 1 diameter was 1 size smaller by IVUS. There were no significant differences in the mean lowest systolic blood pressure (98 vs. 92, P = 0.53), median fluid resuscitation in the first 24 hr (4.9 vs. 5.0 L, P = 0.97), or median 24-hr transfusion requirements (130 vs. 1311 mL, P = 0.11) between the groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from the CT than from IVUS (9 vs. 2). Conclusions The TEVAR has become the standard therapy for blunt aortic injury, despite a dearth of long-term outcome data. The preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. The implications of placing thoracic endografts and whether excessive oversizing results in long-term aortic dilation need to be the focus of long-term studies in these relatively young patients.

Bedside identification of blunt thoracic aortic injury with point-of-care transesophageal echocardiography

Trauma point-of-care ultrasound in the form of the Focused Assessment with Sonography for Trauma (FAST) exam and its evolution into extended FAST have significantly enhanced the diagnostic power of evaluation and resuscitation of the trauma patient; however, these modalities still have limitations in evaluating mediastinal and cardiac pathology. This report demonstrates a case of point-of-care transesophageal echocardiography in the diagnosis of blunt thoracic aortic injury in an unstable patient involved in a motor vehicle collision.