Blunt Traumatic Aortic Injury Research Articles

Endovascular repair for acute aortic syndrome involving the descending aorta

This review paper delves into the acute aortic syndromes, with a particular focus on those affecting the descending thoracic aorta, including acute type B aortic dissection (aTBAD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), blunt traumatic thoracic aortic injury (bTAI), and ruptured aneurysm of the descending thoracic aorta (rDTA). These conditions present with sudden-onset symptoms such as severe chest or back pain, necessitating immediate medical attention. While traditional open surgical repair was historically the mainstay of treatment, advancements in endovascular techniques have revolutionized management approaches. Endovascular treatment offers advantages such as reduced operative time, blood loss, and hospital stay, making it a safer option for high-risk patients. However, it is crucial to carefully evaluate patients for endovascular suitability, considering the potential complications and risks associated with these techniques. This paper aims to provide an updated overview of acute aortic syndromes involving the descending thoracic aorta, analyze available therapeutic options, and review contemporary treatment modalities, shedding light on the technical aspects and considerations guiding clinical decision-making in this complex and life-threatening scenario.

Endovascular Repair Blunt Thoracic Aortic Injury in Adolescent: A Case Series.

Blunt traumatic aortic injury (BTAI) is a rare occurrence in adolescents, yet it is associated with a high mortality rate necessitating immediate treatment. Although endovascular repair has become the preferred treatment for such injuries in adults, its effectiveness in adolescents remains uncertain. Blunt traumatic aortic injury typically presents with concomitant injuries to other organs and carries a high perioperative mortality rate with operative repair (OR). In this report, we describe the treatment of 3 clinical cases of BTAI in adolescents using thoracic endovascular aortic repair (TEVAR). These cases contribute pertinent evidence supporting the efficacy of intravascular repair for BTAI. Operative repair (OR) remains the gold standard for treating BTAI in adolescents. Nevertheless, TEVAR therapy presents a viable alternative for patients with multiple injuries in whom anticoagulation is contraindicated. Further long-term observation is necessary to assess the lasting effects of TEVAR therapy. This study has provided insights into endovascular repair for adolescent BTAT, offering clinicians significant reference material for choosing treatment strategies for adolescent BTAT. The study aims to demonstrate the safety and effectiveness of endovascular repair treatments in a series of clinical cases involving adolescent BTAI.

Early survival benefit of a low-profile endograft in blunt traumatic aortic injury

ObjectivesTo demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. MethodsA prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 US centers between 2017-2021. The primary endpoint was 30-day all-cause mortality. ResultsCohort was mostly male (74%) with a mean age of 42.4 ± 17.2 years treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3; 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42% and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent (NBS) endograft. Technical success was 98% (one early Type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% CI, 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through four years (95% CI, 86.6—99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, of 98.0% at 30 days and 95.8% from six months to four years (95% CI, 84.3—98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. ConclusionsRelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Using Machine Learning to Predict Outcomes of Patients with Blunt Traumatic Aortic Injuries.

The optimal management of blunt thoracic aortic injury (BTAI) remains controversial, with experienced centers offering therapy ranging from medical management to TEVAR. We investigated the utility of a machine learning (ML) algorithm to develop a prognostic model of risk factors on mortality in patients with BTAI. The Aortic Trauma Foundation registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. A STREAMLINE (A Simple, Transparent, End-To-End Automated Machine Learning Pipeline Facilitating Data Analysis and Algorithm Comparison) model as well as logistic regression (LR) analysis with imputation using chained equations was developed and compared. From a total of 1018 patients in the registry, 702 patients were included in the final analysis. Of the 258 (37%) patients who were medically managed, 44 (17%) died during admission, 14 (5.4%) of which were aortic related deaths. 444 (63%) patients underwent TEVAR and 343 of which underwent TEVAR within 24 hours of admission. Amongst TEVAR patients, 39 (8.8%) patients died and 7 (1.6%) had aortic related deaths. (Table 1) Comparison of the STREAMLINE and LR model showed no significant difference in ROC curves and high AUCs of 0.869 (95% CI, 0.813 - 0.925) and 0.840 (95% CI, 0.779 - 0.900) respectively in predicting in-hospital mortality. Unexpectedly, however, the variables prioritized in each model differed between models (Figure 1A-B). The top three variables identified from the LR model were similar to that from existing literature. The STREAMLINE model, however, prioritized location of the injury along the lesser curve, age and aortic injury grade (Figure 1A). Machine learning provides insight on prioritization of variables not typically identified in standard multivariable logistic regression. Further investigation and validation in other aortic injury cohorts are needed to delineate the utility of ML models. Level IIIStudy TypeOriginal research (prognostic/epidemiological).

Anatomic Feasibility of In-Situ Fenestration for Isolate Left Subclavian Artery Preservation during Thoracic Endovascular Aortic Repair Using an Adjustable Needle Puncturing System.

To evaluate the feasibility of thoracic endovascular aortic repair (TEVAR) using the Ankura™ device (Lifetech Scientific, Shenzhen, China) with left subclavian artery (LSA) in-situ fenestration (ISF) using an adjustable puncture device system. It is a single center, retrospective, financially unsupported cohort study of TEVAR performed from 16 February 2007 to 10 January 2023. Inclusion criteria were isolate LSA revascularization for elective or urgent/emergent "zone 2" TEVAR, and the availability of the preoperative computed tomography angiography. Post-hoc analysis identified 52 TEVARs. There were 39 (75.0%) males, and 13 (25.0%) females: median age was 74.5 years (IQR, 65.5-78). Index TEVAR was performed for atherosclerotic aneurysm in 27 (51.9%) cases, dissection-related diseases in 18 (34.6%), penetrating aortic ulcer in 5 (9.6%), and blunt traumatic aortic injury in 2 (3.8%). Access-vessel feasibility rate of TEVAR using the Ankura™ device would have been 98.1% (51/52). Considering the morphology of the aortic arch, ISF TEVAR feasibility would have been 61.5% (32/52). Binary logistic regression analysis identified LSA angulation (OR: 1.1, 95%CI: 1.03-1.14, p = 0.003) to be associated with ISF feasibility using this endograft and a self-centering adjustable needle-based puncture device. Potential feasibility of TEVAR using the Ankura™ endograft with ISF using a self-centering adjustable needle system was 61.5%. Left subclavian artery angulation seems to be the most important and limiting anatomical constraint.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury

SVS Grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with PRISMA guidance. Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% CI 6.7% - 14.9%) for all-cause mortality, 2.9% (95% CI 1.1% - 5.7%) for aorta-related mortality and 3.3% (95% CI 1.4% - 6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data supports nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.

Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results.

Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Pulsatile Deformations of a Conformable Descending Thoracic Aortic Endograft in Aneurysm, Dissection, and Blunt Traumatic Aortic Injury Patients.

This study presents analytic techniques to quantify cardiac pulsatility-induced deformations of thoracic aortic endografts in patients with thoracic aortic aneurysm (TAA), dissection (TAD), and blunt thoracic aortic injury (BTAI) after thoracic endovascular aortic repair (TEVAR). We analyzed 19 image data sets from 14 patients treated for TAA, TAD, and BTAI with cardiac-gated post-TEVAR CTs. Systolic and diastolic geometric models were constructed and diametric, axial, and bending deformations were quantified. For patients with cardiac-gated pre-op scans, the damping of pulsatile diametric distension was computed. Maximum localized diametric distension was 2.4±1.0%, 4.2±1.7%, and 5.5±1.6%, and axial deformation was 0.0±0.1%, -0.1±0.3%, and 1.1±0.6% in the endografts of TAA, TAD, and BTAI cohorts, respectively. Diametric distension damping from pre- to post-TEVAR was ~50%. Diametric and bending deformations were localized at certain axial positions on the endograft, and the inner curve bends more than the centerline, especially adjacent to overlapping regions. The presented techniques support investigation of multi-axial endograft deformations between disease causes and geometric locations on the device. Discretized quantification of deformation is needed to define device fatigue testing conditions and predict device durability in patients. This study demonstrates analytic techniques to quantify discretized deformation of thoracic endografts. Cardiac-resolved computed tomography is sometimes acquired for surgical planning and follow-up, however, the dynamic data are not typically used to quantify pulsatile deformations. Our analytic techniques extract the centerline and surface geometry of the stented thoracic aorta during the cardiac cycle, which are used to quantify diametric, axial, and bending deformations to provide better understanding of device durability and impact on the native anatomy.

Impact of thoracic endovascular aortic repair following blunt traumatic thoracic aortic injury on blood pressure

BackgroundBlunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development. MethodsTwenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation. ResultsThe mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging. ConclusionsHT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis.

Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.

Sex Differences in Blunt Traumatic Aortic Injury from the Aortic Trauma Foundation Global Registry

Trauma is the leading cause of death in people younger than 45 years, and blunt traumatic aortic injury (BTAI) is the second leading cause of death after blunt trauma. There have been reports on variations in physiological response to trauma between men and women, as well as sex/gender disparities in aortic disease outcomes, but there is a gap in the literature on sex differences in patients with traumatic aortic injury. The Aortic Trauma Foundation international prospective multicenter registry was used to examine sex differences in traumatic aortic injury characteristics, management, and outcomes from 2016 to 2022. Data were analyzed by contingency table, stratified and multivariable regression. There were 781 patients with BTAI and complete injury grade information, of whom 182 patients (23%) were female. The mean age was 43.4 ± 18 years, and women were significantly older than men (48 ± 18.6 vs 42.3 ± 17.6 years, P < .0001). A total of 464 patients (59%) underwent thoracic endovascular aortic repair with no significant difference between men (61%, 364 of 599) and women (55%, 100 of 182). Injury severity score and Glasgow coma scores did not differ between women and men. Women more often had pelvic fracture (41% vs 30%, P < .004), splenic injury (31% vs 23%, P < .05), renal injury (22% vs 14%, P < .02), sacral spine fracture (12% vs 6%, P < .02), and sternal fracture (17% vs 10%, P < .02), but these injury patterns were not associated with higher grade aortic injuries. There were no sex differences in the distribution of aortic injury grade. In-hospital mortality was 12%, and aortic-related mortality was 4% for the entire cohort, with no differences between men and women. The presence of sternal fracture appeared to predict higher aortic mortality in women (10% with sternal fracture vs 2% without, P = .05) but not in men (9% with sternal fracture vs 10% without P = .9). There is no difference in mortality between men and women with BTAI. Women with BTAI presented more frequently with intra-abdominal and pelvic injuries, and sternal fractures appear to predict a higher mortality in women with BTAI.

Predicting Mortality in Blunt Abdominal Aortic Trauma- a Novel Approach Utilizing Neural Networks

The aim of this study was to develop an accurate neural network (NN)-based approach to predict in-hospital mortality in patients who sustain blunt traumatic aortic injury (BTAI). Secondary objectives include identifying factors that may play a contributory role in mortality. The 2019 National Trauma Data Bank (NTDB) was queried for International Classification of Diseases, Tenth Edition (ICD-10) codes corresponding to blunt abdominal aortic trauma. Patients with no signs of life upon presentation were excluded from this study. A total of 113 patients were used to train a NN using the following input variables: age, sex, Injury Severity Scale (ISS), presenting Glasgow Coma Scale (GCS), packed red blood cells (RBCs) used in the first 4 hours of presentation, and presenting systolic blood pressure (SBP). The primary outcome of our study was the area under the receiver-operator characteristics curve (AUC), sensitivity, and specificity of our NN with secondary outcomes including the normalized importance ratio of variables used to train the NN. The NN accurately predicted mortality in patients who sustained BTAI with an AUC of 0.93 (Fig), sensitivity of 72%, and specificity of 89%. There were no significant differences in age between the mortality and survival cohorts. There was a higher prevalence of males in the mortality group in addition to a higher ISS, lower GCS, increased number of packed RBCs in the first 4 hours of presentation and a lower presenting SBP. Our NN found transfusion requirements to be the most predictive of mortality followed by ISS. A NN-based approach can accurately predict mortality in BTAI. Additionally, transfusions requirements within the first 4 hours and presenting ISS were found to have the highest predictive value. Furthermore, NN can be utilized as an innovative predictive adjunct in the management of critical trauma.

Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair.

Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.

Blunt traumatic aortic injury in the elderly population

Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. Patients aged 65years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. During the study period, 1322 patients aged 65years and over sustained BTAI and survived past triage. Mean age was 74.7years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P< .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P< .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.

Endovascular therapy in blunt traumatic aortic injuries

Aim: Blunt traumatic thoracic aortic injury (BTTAI) is a catastrophic life-threatening surgical emergency and the second most common cause of death in trauma patients. We retrospectively revealed our results for endovascularly treated BTTAI with early and long-term results. Material and Methods: During January 2009 and January 2022, patients from the emergency department with diagnosed BTTAI were retrospectively revealed. 38 patients all male except two, experienced BTTAI. 5 patients had grade IV, and 21 patients had grade III aortic injuries. Results: Mean age of the patients was 41.7±12.5 years. Technical success was 100%. Early mortality was 7.9%. The mean follow-up period was 49.7±18.3 months. In the follow-up period, there were no TEVAR-related complications. Conclusion: TEVAR is the most suitable treatment for BTTAI in the modern era. Left subclavian artery (LSA) intentional coverage may be performed however surgeon modified fenestrated stent graft (SMFSG) is an effective, economic, fast, and readily available technique for LSA revascularization without additional time.

Blunt traumatic aortic injury to the brachiocephalic and left carotid arteries

BackgroundBlunt traumatic aortic injury (BTAI) is a life-threatening pathology that most commonly occurs after traffic accidents or a fall from a considerable height. We report a rare case of traumatic double transection which included the brachiocephalic artery (BCA) and left carotid artery (LCA) following a motorcycle accident.Case presentationA 52-year-old man was brought to our emergency room for blunt trauma. Urgent computed tomography (CT) indicated BCA and LCA transection. Two weeks after the BTAI, CT indicated an increase in the size of the BCA pseudoaneurysm, a newly developed LCA pseudoaneurysm, and a spread of hematoma. An emergency partial aortic arch replacement including BCA and LCA reconstruction was performed 17 days after the BTAI. The postoperative course was good, and he was discharged 12 days later.ConclusionsAn open aortic repair appeared to be more suited in the present case because the aortic injury occurred in a branched lesion of the aortic arch. It was thought that complete stent graft coverage of the transection lesion would be difficult. Although coexisting multiple system injuries complicate aortic repair, there was a rapid enlargement of the BCA and LCA pseudoaneurysms. Therefore, strict management is needed even in the case of cervical artery injury.

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

This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up. During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1month, at 6months (only in the cases of thoracic aortic dissection), at 1year after the procedure and every 1year thereafter. Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up. Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

A Case of Blunt Traumatic Aortic Injury with a Pseudoaneurysm in the Aortic Arch between the Brachiocephalic and Left Common Carotid Arteries

A Case of Blunt Traumatic Aortic Injury with a Pseudoaneurysm in the Aortic Arch between the Brachiocephalic and Left Common Carotid Arteries

The Role of Surgical and Endovascular Repair of Blunt Traumatic Aortic Injury in the Modern Era: A Single-Center Experience.

Objective:To evaluate the efficacy of chest x-ray (CXR) in blunt traumatic aortic injury (BTAI) as a primary imaging tool in trauma patients. Methods:We retrospectively reviewed our hospital records for blunt thoracic aortic injury patients who had a therapeutic intervention from January 2015 to February 2021. Patients’ characteristics, initial chest x-rays, and computed tomography (CT) scan were extracted and re-evaluated.Results: Eighteen patients matched the criteria of our research. The mean age and the injury severity score (ISS) was 29.8±11.2 and 38.4±14.4, respectively. Seven patients (38.9%) underwent thoracic endovascular aortic repair (TEVAR), and 11 (61.1%) had open surgery. The TEVAR group had significantly lower mean intensive care unit stay days (6.6±3.9 vs. 10.8±6.9 in open aortic repair (OAR), p<0.05). The percentile of patients requiring blood transfusion was significantly lower in the TEVAR group (57% vs. 100% in OAR, p<0.05). Mediastinal widening (66.7%) was the most common finding during the evaluation of initial chest x-rays. Interestingly, 22.2% of the initial x-rays were not remarkable for BTAI.Conclusion:TEVAR is an advantageous choice in the management of BTAI. However, open aortic repair is the optimal decision in certain situations. It is suggested that the Interventional management of the BTAI must be performed by experienced vascular surgeons in a medical center capable of both OAR and TEVAR.

Blunt Traumatic Aortic Injury Management, a French TraumaBase Analytic Cohort

Blunt traumatic aortic injury (BTAI) in severe trauma patients is rare but potentially lethal. The aim of this work was to perform a current epidemiological analysis of the clinical and surgical management of these patients in a European country. This was a multicentre, retrospective study using prospectively collected data from the French National Trauma Registry and the National Uniform Hospital Discharge Database from 10 trauma centres in France. The primary endpoint was the prevalence of BTAI. The secondary endpoints focused chronologically on injury characteristics, management, and patient outcomes. 209 patients were included with a mean age of 43 ± 19 years and 168 (80%) were men. The calculated prevalence of BTAI at hospital admission was 1% (162/15 094) (BTAI admissions/all trauma). The time to diagnosis increased with the severity of aortic injury and the clinical severity of the patients (grade 1: 94 [74, 143] minutes to grade 4: 154 [112, 202] minutes, p = .020). This delay seemed to be associated with the intensity of the required resuscitation. Sixty seven patients (32%) received no surgical treatment. Among those treated, 130 (92%) received endovascular treatment, 14 (10%) open surgery (two were combined), and 123 (85%) were treated within the first 24 hours. Overall mortality was 20% and the attributed cause of death was haemorrhagic shock (69%). Mortality was increased according to aortic injury severity, from 6% for grade 1 to 65% for grade 4 (p < .001). Twenty-six (18.3%) patients treated by endovascular aortic repair had complications. BTAI prevalence at hospital admission was low but occurred in severe high velocity trauma patients and in those with a high clinical suspicion of severe haemorrhage. The association of shock with high grade aortic injury and increasing time to diagnosis suggests a need to optimise early resuscitation to minimise the time to treatment. Endovascular treatment has been established as the reference treatment, accounting for more than 90% of interventional treatment options for BTAI.