Blunt Traumatic Aortic Injury Research Articles

One Year on: Test Your Knowledge From March 2020

1. A retrospective, observational, multicenter study evaluated aortic remodeling and associated complications in 47 patients treated with thoracic endovascular aneurysm repair (TEVAR) for blunt traumatic aortic injuries (BTAI). Which of the following is correct?1A.Aortic remodelling is more common in young patientsB.Aortic remodelling occurs mainly during the first year after TEVAR and its occurrence thereafter is rare.C.Aortic remodelling is clearly related to endograft oversizingD.There is no correlation between remodeling and associated complicationsE.None of the above

TEVAR versus open repair of blunt traumatic descending aortic injury in polytraumatic patients involved in motor vehicle accidents

BackgroundThoracic endovascular aortic repair (TEVAR) is the standard-of-care for treating traumatic aortic injury (TAI). Few retrospective studies compared TEVAR to open repair in blunt traumatic aortic injury (BTAI). Our objectives were to compare the early outcomes of TEVAR for blunt traumatic descending aortic injury to open repair (OR) in polytraumatic patients involved in motor vehicle accidents (MVA).ResultsBetween February 2005 and April 2017, 71 patients with TAI due to MVA presented to our institution. All patients with descending aortic injuries were considered for open repair (n = 41) or TEVAR (n = 30) if there was no contraindication. The primary outcome was mortality, and secondary outcomes were stroke, paraplegia, intensive care unit (ICU), and hospital stay.The mean age was 28.4 ± 10.1 years in the OR group and 33.3 ± 16.6 years in TEVAR-group (P = 0.13). The injury severity scores were 41 ± 10 in the OR group and 33 ± 17 in the TEVAR group (P = 0.03). Patients in the OR group underwent emergency repair with a mean time of 0.56 ± 0.18 days from arrival. The TEVAR group had a longer time interval between arrival and procedure (2.1 ± 1.7 days, P = 0.001). The OR group had more blood transfusion (24 (58.5%) vs. 8 (27.5%), P = 0.002), renal impairment (6 (14.6%) vs. 1 (5.50%), P = 0.23), and wound infection (21 (51.2%) vs. 3 (10%), P < 0.001). Three TEVAR patients had a perioperative stroke compared to two patients in the OR group (P = 0.64). There was no difference in the mean ICU (6 ± 8.9 vs. 5.3 ± 2.9 days; P = 0.1) or hospital stay (20.1 ± 12.3 vs. 20.1 ± 18.3, P = 0.62) between the two groups. There were four deaths in the OR group and none in the TEVAR group (P = 0.13).ConclusionThe results of TEVAR were comparable with the open repair for traumatic aortic injury with good early postoperative outcomes. TEVAR repair could be associated with lower mortality, blood transfusion, and infective complications. However, the complexity of the injury and technical challenges were higher in the open group.

Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution.

Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8±13.6years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n=75, 48.7%), acute type B aortic dissections (n=46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n=28, 18.2%), and blunt traumatic aortic injuries (n=5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n=75, 48.7%), zone 3 (n=66, 42.9%) and zone 4 (n=13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.

Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients

The administration of unfractionated heparin (UFH) during endovascular repair of blunt traumatic aortic injury (BTAI) is controversial. The aim of the study is to report the early outcomes of patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI, and to assess the individualized intraoperative use and dose of UFH. This is a retrospective analysis including consecutive patients treated with TEVAR for BTAI of the descending aorta between January 1st, 2005 and December 31st, 2018. Intraoperative use and doses of UFH were analyzed. Primary outcome included a reintervention because of new onset bleeding and/or thromboembolic complication and 30-day mortality. Technical success, injury severity score (ISS), timing of treatment, and neurologic deterioration were secondary outcome. Thirty-six patients with a mean age of 47 ± 18 years, 30 males (83%), were included. Intraoperative administration of UFH was recorded in 30/36 patients (83%) with a mean dose of 4750 ± 2180 IU. Two patients had no UFH because of extensive intracranial hemorrhage or suspected relevant liver laceration, respectively; 1 died in theatre, 1 was already anticoagulated having a mechanical aortic valve, and in 2 no information about heparin use was found. During 30 days of follow-up, 3 patients died (8%; 3/36): 1 patient with completely transected aorta died on-table and 2 on the fifth postoperative day, 1 from trauma-associated brain injury and 1 with multi organ failure. No bleeding or thromboembolic complication requiring reintervention occurred in any patient during 30 days follow-up. In 3 patients partial unintentional coverage of the left common carotid artery occurred, resulting in technical success of 89% (32/36). Mean ISS was 43 ± 15. Thirty-five patients (97%) were severely injured having an ISS ≥ 25. Twenty-nine patients (81%) were treated within 24 hr and 6 patients (17%) within 1 week. No stroke or spinal cord ischemia was observed. Systemic heparinization in different doses during TEVAR for BTAI can be safe with no intraoperative bleeding or thromboembolic complications in early postoperative period.

Chronic Blunt Traumatic Thoracic Aortic Injuries

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.

P.53 Ascending Aorta Diameter and Pulse Wave Velocity are Increased and Local Hemodynamic is Disrupted in Patients with Blunt Traumatic Thoracic Aortic Injury Treated by TEVAR

BackgroundThoracic endovascular aortic repair (TEVAR) is becoming the preferred treatment option to repair the proximal descending aorta after rupture following blunt traumatic injury. However, hemodynamic and mechanic implications of this intervention are poorly understood. Exploiting the possibilities of 4D flow magnetic resonance imaging, hemodynamics, stiffness and local dilation in the ascending aorta in patients following aortic repair by TEVAR are studied.MethodsFifteen apparently healthy individuals who underwent TEVAR implantation after traumatic descending aortic injury and 44 healthy volunteers (HV) underwent 4D flow-MRI. Ascending aorta pulse wave velocity was computed [1]. Moreover, at eight planes equally distributed in the ascending aorta systolic flow reversal ratio, i.e. relative amount of backward flow during systole, and in-plane rotational flow, measuring the strength of helical flow, were computed [2,3].ResultsTEVAR patients and HV did not differ in terms of age, sex, BSA and blood pressure (Table). However, compared to HV, TEVAR patients showed reduced in-plane rotational flow in the distal ascending aorta in patients with TEVAR and increased backward systolic flow in the whole ascending aorta (Figure). Patients with TEVAR had a stiffer ascending aorta, with pulse wave velocity higher compared control (7.8 ± 4.2 vs 5.3 ± 1.9, p = 0.004). Finally, aortic root and ascending aorta diameters were larger in TEVAR patients compared to HV (Table).ConclusionsThe implantation of TEVAR in apparently healthy individuals after traumatic rupture of the proximal descending aorta is associated with altered hemodynamics, higher stiffness and larger aortic diameter in the region proximal to the TEVAR.TableHealthy volunteersTEVAR patientspN4415Age [years]40 ± 1243 ± 100.392Sex [% male]66800.075Years from intervention [years]N/A10.3 ± 6.4N/ABody surface area [m2]1.87 ± 0.151.96 ± 0.230.088Systolic blood pressure [mmHg]127 ± 19131 ± 150.389Diastolic blood pressure [mmHg]70 ± 1174 ± 90.198Aortic root diameter [mm]31 ± 434 ± 40.026Ascending aorta diameter [mm]28 ± 432 ± 30.003Ascending aorta PWV [m/s]5.3 ± 1.97.8 ± 4.20.004FigureIn-plane rotational flow (IRF, left) and systolic flow reversal ratio (SFRR, right) in healthy volunteers (black) and TEVAR patients (yellow) in the proximal (planes 1 to 4) and distal (planes 5 to 8) ascending aorta. Stars show statistically-significant differences (p < 0.05).

Patients with blunt traumatic thoracic aortic injury treated with TEVAR present increased flow dynamics alterations and pulse wave velocity: a 4D flow CMR study

Abstract Background Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of blunt traumatic thoracic aortic injuries. Aortic flow dynamics and mechanical implications of this intervention are poorly investigated and may be of particular interest in the long-term follow-up of these mostly young patients. Purpose To assess whether the presence of TEVAR in a cohort of otherwise healthy subjects was related to dilation of the proximal aorta or increase in aortic stiffness and flow alterations. Methods Nineteen patients who underwent TEVAR implantation after a traumatic injury of the thoracic descending aorta (DAo) (10.0±6.1 years from intervention) and 44 healthy volunteers (HV) underwent 4D flow CMR to compute ascending aorta (AAo) pulse wave velocity (PWV), a marker of aortic stiffness, systolic flow reversal ratio (SFRR), quantifying backward flow during systole and in-plane rotational flow (IRF), measuring in-plane strength of helical flow. IRF and SFRR were assessed at 20 planes between the sinotubular junction and the mid thoracic DAo. Aortic diameters were measured using double-oblique cine CMR. Results Patients with TEVAR and HV did not differ in age, sex, body surface area, blood pressure and DAo diameter distal to TEVAR (Table). However, TEVAR patients presented larger diameters at the sinus of Valsalva and AAo, increased AAo PWV and strong flow alterations: IRF was reduced from the distal AAo to the proximal DAo, while SFRR was increased in the whole thoracic aorta (Figure). Conclusions In patients with blunt traumatic thoracic aortic injury treated with TEVAR the aorta proximal to TEVAR is dilated, stiffer and present potentially pathogenic flow conditions. Longitudinal studies are needed to assess whether these alterations have prognostic value and may improve clinical prevention and management of these patients. Figure 1. IRF and SFRR in healthy vs TEVAR Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been funded by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (PI19/01480). Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management.

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.

Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations.

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. 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. 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. 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.

Anatomic Feasibility of Off-the-Shelf Thoracic Single Side-Branched Endograft in Patients With Blunt Traumatic Thoracic Aortic Injury

The advent of thoracic single side-branched endograft (TSSBE) has provided a treatment option to obviate the need for open cervical debranching of the left subclavian artery (LSA), thereby enabling total endovascular incorporation of the LSA during thoracic endovascular aortic repair (TEVAR). In a previous study of patients with type B aortic dissection who had required zone 2 TEVAR, the anatomic feasibility of this device was demonstrated to range from 28% to 35%, suggesting limited applicability of the currently available designs. The objectives of the present study were twofold: (1) to evaluate the anatomic feasibility of TSSBE in blunt traumatic thoracic aortic injury (BTAI) patients who would require LSA revascularization; and (2) to describe the anatomic characteristics of the supra-aortic arch branches that could be used to improve future device design. A retrospective review was performed of BTAI patients who had undergone TEVAR at a single institution from November 2013 to October 2018. Preoperative computed tomography angiograms were analyzed using three-dimensional reconstruction to quantify the aortic diameter, distance and arc length between branch vessels, and the LSA diameter and length. We calculated the proportion of patients who had metall aortic and LSA anatomic requirements for TSSBE proposed by investigational protocols. We also assessed the effect of anatomic requirement modifications on device suitability. Finally, we assessed the local anatomic relationship between the supra-aortic branches. A total of 41 patients (63% men; median age, 39years; range, 23-88years; 68% normal aortic arch pattern, 32% bovine aortic arch pattern) with BTAI who had required TEVAR involving the LSA and were, thus, considered potential candidates for TSSBE were included. Of the 41 patients, 13 (32%; 7 with a bovine aortic arch and 6 with a normal aortic arch) had metall proposed aortic and LSA anatomic requirements for TSSBE. An appropriate aortic diameter, LSA diameter, and LSA length to its first branch were observed in 100%, 95%, and 66% of the patients, respectively. An insufficient distance between the arch branch vessels, observed in 41%, was the most common exclusionary criterion. The median clock-face position of the LSA was 12:00 (interquartile range, 30minutes) in the normal arch group and 11:45 (interquartile range, 15minutes) in the bovine arch group. Despite the numerous potential advantages of TSSBE, only 32% of patients with BTAI requiring LSA revascularization had metall the aortic and LSA anatomic requirements, justifying the need for additional designs. Better characterization and mapping of the aortic arch branches will improve future device design and application.

Man with trauma following motorcycle crash.

A 56-year-old male presented to the emergency department (ED) following a frontal impact motorcycle accident. The patient was pale with persistent hypotension, tachypnea, and tachycardia along with bilateral lower limbs paralysis and a complete loss of sphincter functions. Patient was intubated, and transesophageal echocardiography performed by attending emergency physician at ED critical care bayshowed the transverse and longitudinal view of the descending aorta with hypoechoic, well-defined, crescent-shaped thickening of anterior aortic wall suggestive of intramural hematoma (Figures 1, 2; Supporting Information Videos S1 and S2). Computed tomography (CT) showed fracture T11 vertebra, intramural hematoma, and peri-aortic hematoma along the arch of the aorta extending down to upper abdominal aorta at the level of T12 (Figure 3). Traumatic thoracolumbar spine fracture with a concomitant blunt aortic injury is uncommon (1.4%) but potentially fatal.1 Most fractures associated with blunt traumatic aortic injury occurred at the level of T11–L2 vertebra (62%).1 ED transesophageal echocardiography is a potential new imaging adjunct in resuscitation.2-4 Even though the surface ultrasound has become an important bedside imaging tool in initial management of trauma patients in ED, its limitations include poor evaluation of vascular pathologies (ie, BTAI).5 The role of ED transesophageal echocardiography for the early detection of BTAI in hemodynamically unstable trauma patient was reported by Osman et al.6 The patient was managed conservatively and was discharged from spinal intensive care unit after day 10. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Thoracic Aortic Dilation after Endovascular Repair of Blunt Traumatic Aortic Injury

Thoracic endovascular aneurysm repair (TEVAR) has become the current standard of care for emergent treatment of traumatic blunt thoracic aortic injuries (BTAI). Although aortic dilation (AD) of the infrarenal neck after EVAR for aortic aneurysms has been studied, changes in aortic diameter after TEVAR for BTAI is not well understood. This study aims to characterize changes in thoracic aortic diameter after stent-graft placement in the setting of nonaneurysmal traumatic aortic injury. A single-center, retrospective review was performed involving patients presenting with BTAI treated with TEVAR. Only patients with at least 12months follow-up were included. Aortic diameter, defined as the outer-to-outer diameter on 3D center-line imaging, was measured at six locations along the proximal and mid thoracic aorta. The first postoperative CT (≤1month) served as a baseline from which interval measurements were compared. Twenty patients with BTAI treated from 2011 to 2017 had adequate imaging available for review and were included in this study cohort. Median follow-up time was 46.8 (12-80, range) months. At the latest follow-up, AD occurred at all measured locations within the endograft, starting from the proximal graft edge (0.62±0.69mm, P=0.027) to the distal graft edge (1.21±1.28mm, P=0.003). AD was most pronounced in the distal graft segment 2cm proximal to the distal graft edge, with a mean AD of 1.32±1.59mm (+5.3%, P<0.001). At this location, AD was found to increase in a linear manner with an estimated rate of 0.67±0.20mm/year (P=0.006). The native aorta proximal and distal to the endograft was not found to significantly dilate during follow-up (P=0.280-0.897). Seventy percent of the patients were found to have AD >5%. The amount of AD was not found to be associated with either graft oversizing (P=0.151) or age (P=0.340). There were no cases of graft migration, erosion, or endoleak. AD is a common benign finding after TEVAR for BTAI. AD is most pronounced at the near the distal end of the stent graft. In late-term follow-up, there are no known associated complications related to AD.

Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department.

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. 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.

Anatomic Feasibility of Off-the-shelf Thoracic Single Side-branched Endograft in Patients With Blunt Traumatic Thoracic Aortic Injury

The advent of thoracic single side-branched endograft (TSSBE) provides a treatment option to obviate the need for open cervical debranching of the left subclavian artery (LSA), thereby enabling total endovascular incorporation of the LSA during thoracic endovascular aortic repair (TEVAR). In a previous study in patients with type B aortic dissection who required zone 2 TEVAR, anatomic feasibility of this device has been demonstrated to range between 28% and 35%, suggesting limited applicability of currently available designs. The objective of this study was twofold: (1) to evaluate the anatomic feasibility of TSSBE in an unselected population of blunt traumatic thoracic aortic injury (BTTAI) patients who would require LSA revascularization; and (2) to describe the anatomic characteristics of the aortic arch branches that can be used to improve future device design. A retrospective review was performed on BTTAI patients who underwent TEVAR at a single institution between November 2013 and October 2018. Preoperative computed tomography angiography images were analyzed using three-dimensional reconstruction to quantify aortic diameter, distance and arc length between branch vessels, and target side branch vessel diameter and length. We calculated the percentage of patients that met all anatomic requirements for TSSBE proposed by investigational protocols that have been published, and plotted each branch vessel in relation to the left common carotid artery in cases of normal aortic arch and the innominate artery in cases of bovine aortic arch. There were 41 patients (63% men; median age, 39 years [range, 23-88 years]; 68% normal aortic arch pattern, 32% bovine aortic arch pattern) with BTTAI considered potential candidates for TSSBE. Of these, 13 (7 bovine aortic arch, 6 normal aortic arch; 31.7%) met all proposed anatomic requirements for TSSBE: appropriate aortic diameter, LSA diameter, and LSA length to its first branch were observed in 100%, 95%, 66% of the patients, respectively. Insufficient distance between arch branch vessels, observed in 41%, was the most common exclusionary criterion. Figs 1 and 2 depict the absolute positions of individual branch vessels relative to the left common carotid artery and to the innominate artery in the 0 axis, respectively. Despite numerous potential advantages of TSSBE, only 32% of patients with BTTAI requiring LSA revascularization met all the anatomic requirements, justifying the need for additional designs. Improved characterization and mapping of the aortic arch branches will improve future device design and application.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Blunt Aortic / Inferior Vena Cava Injury: Are We Consistently Providing the Same Level of Care?

Major vascular traumatic injuries have a higher pre-hospital and in-hospital mortality rate. The different mechanisms of injury and anatomy of the aorta and inferior vena cava (IVC) make the management a constant challenge to surgeons and clinicians. Blunt traumatic aortic injury (BTAI) can occur at the thoracic or abdominal level, each of which possesses different considerations. Blunt traumatic inferior vena cava injury (BTIVCI) also has important diagnostic challenges since the lesion may not be as evident in the IVC as compared to the aorta, possibly due to lower caval pressures or the ability to self-tamponade from adjacent structures. Endovascular management has significantly increased in the past years, and despite an improvement in mortality, the approach to aortic and IVC injuries is not well standardized. Diagnostic imaging helps to classify the extent of the lesions and guide towards the best therapeutic options for each case. Conservative management, in some cases, has shown to reduce mortality, and close follow-up has proven good outcomes. Future research will provide more evidence to determine the best approach to BTAI and BTIVCI for better long-term outcomes. This article aims to provide an updated review of the current literature regarding diagnosis, classification, and management of BTAI and BTIVCI.

Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center

Blunt thoracic aortic injury treatment has evolved over the past decade particularly with respect to endovascular intervention options. We investigated the trends in blunt thoracic aortic injury management and outcomes over an 11-year span at the sole tertiary referral center in our state. We retrospectively reviewed all patients who presented to our institution with blunt traumatic aortic injury between 2007 and 2017. Baseline demographics including aortic injury grade, injury severity score, and abbreviated injury scale were collected. Outcomes were compared by type and timing of treatment, which included either nonoperative management, endovascular repair, or open surgical repair. Bivariate and multivariable analyses were performed to examine treatment group differences and factors associated with 30-day mortality. In total, 229 patients were reviewed. The distribution of injury severity was grade 1 (30%), grade 2(8%), grade 3 (30%), and grade 4 (31%). Overall, 27% of patients underwent endovascular repair, 29% open surgery, and 44% definitive nonoperative management. Over the study period, there was a dramatic decline in open surgery and a corresponding rise in endovascular treatment. Thirty-day mortality for the entire cohort was 22%. Mortality by treatment subgroup was 30% for nonoperative management, 8.2% for endovascular treatment, and 21% for open surgery. Delaying endovascular or open surgical treatment by at least 24 hours after admission was associated with significantly improved 30-day survival. Procedural intervention, whether endovascular or surgical, is associated with improved mortality compared with nonoperative treatment. Delayed intervention, particularly in the case of high-grade injuries, may allow for initial patient stabilization and improved outcomes.

Influence of Thoracic Endovascular Repair on Aortic Morphology in Patients Treated for Blunt Traumatic Aortic Injuries: Long Term Outcomes in a Multicentre Study

The aim of this study was to evaluate aortic remodelling and associated complications in patients treated by thoracic endovascular aneurysm repair (TEVAR) for blunt traumatic aortic injuries (BTAI). This was a retrospective, observational, multicentre study. Remodelling was considered as aortic diameter variations of >2mm and distal graft and aortic axis angle modification measured by computed tomography angiography (CTA). The predefined levels of measurement were the proximal end of the graft (D1: landing in zone [LZ] 2; D2: LZ 3); distal end (D3); and control measurement (D4) 15mm beyond D3. Survival, procedure, graft, and/or radiation exposure related complications were registered. CTA was required within three months and at one, six, and 10 years post-operatively. Between 2004 and 2017 52 patients were treated; 47 were included for remodelling analysis (five immediate deaths were excluded); median age was 47 years (range 20-80 years). Mean TEVAR oversizing was 19.6%±9.7% (range 5%-35%). Following a median follow up of 67.4±56.1 months (range 14-153 months) survival at one, three, six, and 10 years was 90.4% (standard error [SE] 4.1%), 88.3% (SE 4.5%) 84.8% (SE 5.5%), and 84.8% (SE 5.5%), respectively. There were no procedure/graft related complications except for one late intramural haematoma that required re-intervention. Freedom from aortic remodelling at one, six, and 10 years was 85.1% (SE 5.2%), 30.9% (SE 8.6%), and 24.7% (SE 8.8%), respectively. The increase in D1/D2 and D3 diameters were influenced by time from intervention (both p<.001), age (p<.001 and p=.002, respectively) and sealing in zone 2 (p=.027 and p=.042, respectively). For every 10% increase in oversizing, proximal neck diameter remodelling was 3.4% (p=.05). The distal axis decreased over time (p<.001; significant between three and six years). TEVAR is safe for BTAI in the mid to long term. This study reports a correlation between time, oversizing, and remodelling, but the level of adverse events was low.

Blunt Traumatic Aortic Injury in the Pan-scan Era.

In the era of frequent head-to-pelvis computed tomography (CT) for adult blunt trauma evaluation, we sought to update teachings regarding aortic injury by determining 1) the incidence of aortic injury; 2) the proportion of patients with isolated aortic injury (without other concomitant thoracic injury); 3) the clinical implications of aortic injury (hospital mortality, length of stay [LOS], and rate of surgical interventions); and 4) the screening value of traditional risk factors/markers (such as high-energy mechanism and widened mediastinum on chest x-ray [CXR]) for aortic injury, compared to newer criteria from the recently developed NEXUS Chest CT decision instrument (DI). We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest studies at 10 Level I trauma centers with the following inclusion criteria: age > 14years, blunt trauma within 6hours of ED presentation, and receiving chest imaging duringED trauma evaluation. Of 24,010 enrolled subjects, 42 (0.17%, 95% confidence interval [CI]= 0.13% to 0.24%) had aortic injury. Most patients (79%, 95% CI= 64% to 88%) had an associated thoracic injury, with rib fractures, pneumothorax/hemothorax, and pulmonary contusion occurring most frequently. Compared to patients without aortic injury this cohort had similar mortality (9.5%, 95% CI= 3.8% to 22.1% vs. 5.8%, 95% CI= 5.4% to 6.3%), longer median hospital LOS (11days vs. 3days, p<0.01), and higher median Injury Severity Score (29 vs. 5, p<0.001). High-energy mechanism and widened mediastinum on CXR had low sensitivity for aortic injury (76% [95% CI= 62% to 87%] and 33% [95% CI= 21% to 49%], respectively), compared to the NEXUS Chest CT DI (sensitivity 100% [95% CI= 92% to 100%]). Aortic injury is rare in adult ED blunt trauma patients who survive to receive imaging. Most ED aortic injury patients have associated thoracic injuries and survive to hospital discharge.Widened mediastinum on CXR and high-energy mechanism have relatively low screening sensitivity for aortic injury, but the NEXUS Chest DI detected all cases.

A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes.

Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). Patient mortality, survival and reoperation rate. Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

A Level 1 Trauma Center Experience: Is Endovascular Repair All Good for Blunt Traumatic Aortic Injury?

Introduction: Since blunt traumatic aortic injury (BTAI) carries a high mortality rate up to 10-30% [1] especially when combining with brain injury and severe thoraco-abdominal visceral organ injuries, urgent endovascular or open aortic repair (AR) for Grade (Gr) II-IV BTAI is mandatory. Endovascular aortic repair (EAR) is the first-line choice for BTAI involving descending aorta in concern of coagulopathy. [2] In case of blunt traumatic ascending aorta injury (BTAAI), EAR would be challenging. [3] This study aims at analyzing accuracy of diagnosis on computed tomography (CT), surgical strategy and results of various kinds of BTAI, including traumatic type A aortic dissection (AD) and intramural hematoma (IMH) in our Level 1 Trauma Center. Methods: From Jan. 2015 to Jan. 2019, all BTAI patients undergoing surgery are retrospectively reviewed. BTAI grading is modified with Gr IIa as IMH, Gr IIb as AD and Gr X as periaortic hemorrhage. Mechanism of injury, grade of BTAI on CT, associated injuries, injury severity score (ISS), visit-to-operation time, operative procedures, post-operative complications and re-intervention, operation-to-mortality time, cause of mortality and aortic remodeling on series of follow-up CT were recorded. Results: Total 43 patients presented 5 Gr IIa (1 type A IMH, 4 type B IMH), 11 Gr IIb (4 type A AD, 7 type B AD), 15 Gr III, 8 Gr IV and 4 Gr X BTAI. The mean ISS was 31±9. 65.1% patients got associated injuries in lungs, 44.2% in thoracic cage, 41.9% in abdomen and 39.5% in brain. Mean visit-to-operation time was 2.85 hours. Patients received hybrid AR or EAR with proximally landing at 15 Zone 2, 3 Zone 1, 2 Zone 0 and 22 beyond Zone 3. Associated operations included 10 brain, 10 abdominal, 6 orthopedic and 2 ECMO operations. There were 3 circulatory collapses before or during EAR and all of which died. 6 out of 13 mortality were found exacerbating intra-cranial and intra-abdominal hemorrhage after AR. 24-hour mortality and inhospital mortality were 20.9% and 30.2% (procedure related 38.5%, brain injury 38.5%, abdomen injury 15.4%, lung injury 7.6%). 60% patients with BTAAI underwent EAR and hybrid AR with 100% and 50% mortality respectively. Early complication rate was 7.1% with aortic valve entrapment and acute kidney injury. Re-intervention rate was 2.3% with left subclavian artery steal syndrome. Aortic healing in Gr IIa, Gr III, Gr IV and Gr X BTAI were 100%. For Gr IIb BTAI, there were 66.7% FL thrombosis beyond the aortic graft and 16.7% aortic healing. Conclusion: Diagnosis for BTAI could be mimicked by disrupted intercostal arteries, azygos vein and inferior vena cava. Exacerbations of ongoing intracranial and thoraco-abdominal hemorrhage are main causes of death if EAR is routinely applied as priority. EAR for BTAAI possessed 100% mortality in our series due to unskilled graft deployment and preoperative spinal shock. However, early EAR before aortic exsanguination and circulatory collapse has promising salvage rate and aortic remodeling in other conditions.Figure 2Associated injuries, causes of mortality and surgical outcomes of BTAI.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Nothing to disclose