Blunt Traumatic Thoracic Aortic Injury Research Articles

The effect of TEVAR for blunt traumatic thoracic aortic injury on maximal aortic diameter: Mid- and long-term outcome.

Objective Thoracic endovascular aortic repair (TEVAR) has become the standard of care for blunt thoracic aortic injury (BTAI). Long-term effects of TEVAR on the aortic diameter are not well studied. This study evaluates the effect of TEVAR for BTAI on the aortic diameter in mid- and long-term follow-up. Methods All patients treated with TEVAR for BTAI between August 2000 and May 2016 were included. Maximum aortic diameter was measured at four predetermined thoracic aortic levels in the preoperative and first postoperative CT angiography (CTa) and in the last control CTa or MR angiography: 1 cm proximal (D1) and 1 cm distal to the left subclavian artery (D2), 3 cm distal to the left subclavian artery (D3) and 3 cm proximal to the celiac trunk (D4). Results A total of 27 patients (20 men, mean age 40 years (±17.55) were included. Mean follow-up time was 90 months (±48.36)). No re-interventions were needed. Mean growth of aortic diameter at level D1, D2, D3 and D4 was 0.22 mm ± 3.66, 1.79 mm ± 3.82, 0.73 mm ± 4.18 and –1.06 mm ± 2.82, respectively, when comparing last follow-up to the preoperative imaging without any statistical significant differences. When comparing the preoperative diameter with the first postoperative CT, only a statistical significant growth of 2.81 mm ± 2.69 was seen at level of D2 ( p < 0.05) Conclusion During mid- to long-term follow-up, a temporary significant increase of the maximum aortic diameter was seen at level D2 in the direct postoperative phase This increase was not associated with clinical events and suggests long-term efficacy of TEVAR after BTAI.

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

Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100min (95%CI 63.5-136.5min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.

Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience.

Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear. From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter. The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up. This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.

Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury.

Blunt traumatic thoracic aortic injury (BTAI) is a life-threatening surgical emergency associated with mortality up to 8000 per year, most commonly caused by rapid acceleration/deceleration injury sustained through motor vehicle accident and/or blunt thoracic trauma. BTAI has high pre-hospital mortality following the primary injury, with only 10% to 15% of patients surviving long enough to reach the hospital. Open surgical repair had remained the standard treatment option for BTAI since successfully introduced in 1959. However, with technological advances, thoracic endovascular repair (TEVAR) offers an alternative treatment option for BTAI. TEVAR is a less invasive surgical approach for management of these already critical patients; many reports have described favourable early outcomes.Thoracic endovascular repair may appear to be superior to open repair for treatment of BTAI. However, its long-term results and efficacy remain unknown. No randomised controlled trials (RCTs) have provided evidence to support the superiority of the endovascular approach versus open repair in the treatment of BTAI. This review aims to address this matter. This is an update of a review first published in 2015. To determine whether use of thoracic endovascular repair (TEVAR) for treatment of blunt traumatic thoracic aortic injury (BTAI) is associated with reduced mortality and morbidity when compared with conventional open surgery. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 20 August 2018. We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI. Two review authors independently reviewed all RCTs identified by the Cochrane Vascular Information Specialist. We found no RCTs that met the inclusion criteria for this review. We found no RCTs conducted to determine whether use of TEVAR for the treatment of BTAI is associated with reduced mortality and morbidity when compared to conventional open repair. Hence, we are unable to provide any evidence to guide the treatment option for this life-threatening condition. To perform a randomised controlled trial to clarify the optimal management of BTAI would be highly challenging due to the natural history of the condition. Despite the lack of RCT evidence, clinicians are moving forward with endovascular treatment of BTAI on the basis of meta-analyses of cohort studies and large clinical series.

Chimney parallel grafts and thoracic endovascular aortic repair for blunt traumatic thoracic aortic injuries: A systematic review.

Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an 'endovascular first' approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising 'off-the-shelf' stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.

PC200. Midterm Outcomes After Thoracic Endovascular Aortic Repair of Blunt Traumatic Thoracic Aortic Injury

PC200. Midterm Outcomes After Thoracic Endovascular Aortic Repair of Blunt Traumatic Thoracic Aortic Injury

Pearls and pitfalls in imaging of blunt traumatic thoracic aortic injury: a pictorial review.

Blunt thoracic aortic injury (TAI) occurs most frequently as a sequelae of high impact deceleration such as high-velocity road traffic accidents and falls from height. The burden of mortality and morbidity is high, however advances in pre-hospital care, diagnostic imaging and endovascular therapies have improved outcomes in this group of patients. Emergent treatment depends on accurate, early diagnosis by the radiologist. It is therefore of paramount importance that radiologists are familiar with both the direct (intimal flap, pseudoaneurysm, aortic contour irregularity and contrast extravasation) and indirect (periaortic haematoma) imaging findings of TAI. Furthermore, it is critical that technical (breathing artefact and cardiac motion artefact) as well as anatomical (ductus diverticulum, aortic spindle and mediastinal structures which imitate periaortic haematoma) pitfalls are recognised to avoid misdiagnosis. This pictorial review will help the diagnostic radiologist to recognise the patterns of injury and imaging features associated with TAI, as well as highlighting potential mimics when interrogating CTangiography (CTA) in major trauma.

The Evaluation of Aortic Diameter Changes During Long-Term Follow-Up After Endovascular Treatment of Acute Blunt Traumatic Thoracic Aortic Injuries.

To evaluate the variations in aortic diameters and long-term results in patients who underwent thoracic endovascular aortic repair (TEVAR) for acute blunt traumatic thoracic aortic injuries (BTTAIs). We retrospectively evaluated 23 patients with a mean age of 39 years (range: 17-74 years) who underwent TEVAR for BTTAI between October 2000 and November 2014. All of the patients underwent computed tomography angiography (CTA) before hospital discharge as a baseline imaging for the subsequent follow-up examinations. The technical success, overall survival, and complications were evaluated. Furthermore, the aortic diameters outside of the stent-graft (1 cm proximal and 1 cm distal to the stent-graft) and the aortic diameters within the stent-graft (2 cm distal to the proximal end and 2 cm proximal to the distal end) were assessed. The diameters at baseline on CTA were compared with those of the latest available follow-up examination. Technical success was 100% with a mean follow-up of 65.4 months (range: 12-171 months). No death was registered, and 2 (8.7%) of 23 endograft-related complications (1 stent-graft distal infolding and 1 endoleak 2 and 4 months after the procedure, respectively) were observed. An increase in aortic diameter either proximal or distal to the stent-graft (mean value 0.7 and 0.5 mm, respectively) or within the stent-graft (mean value of 0.5 mm for both proximal and distal diameters) was registered (mean follow-up at 65.4 months, range: 12-171 months). Aortic dilatation following TEVAR for BTTAI is minimal during long-term follow-up. Endovascular treatment represents a durable and safe option in acute BTTAIs.

Long-Term Outcomes of Thoracic Endovascular Aortic Repair Focused on Bird Beak and Oversizing in Blunt Traumatic Thoracic Aortic Injury

The acute aortic arch angle and narrow aortic diameter in young patients may lead to bird-beak configuration and excessive oversizing of the stent graft in thoracic endovascular aortic repair (TEVAR) for blunt traumatic thoracic aortic injury (BTTAI). Little is known about the association of these factors and complications in long-term follow-up. We evaluated the long-term outcomes in terms of complications, reinterventions, and survival, focusing on the effects of bird-beak configuration and oversizing. This prospective cohort study included patients who underwent TEVAR for BTTAI in our department between October 1999 and January 2015. The main outcomes were migration, collapse, intragraft mural thrombus, reintervention, and survival and their association with oversizing and bird-beak configuration. Thirty-four patients were included. Median age was 36years, and 21% were women. Mean graft oversizing was 19% (range: 8-27%) at the proximal end and 27% (range:, -20% to 50%) at the distal end. Mean follow-up was 98months (12-198months). Seven patients presented intragraft mural thrombus, one of whom developed an occlusive parietal thrombosis 1 year after the procedure. Four patients (9%) required reintervention: postoperative revascularization of the left subclavian artery in 2 cases and aortic reinterventions in 2 others. No migration or mortality was seen during follow-up. Bird-beak configuration was seen in 65%: the mean protrusion extension was 16mm (standard deviation [SD]: 7.4mm) and the mean angle was 51° (SD: 16°). The association between the complications and bird beak was not statistically significant. Patients with complications had significantly higher proximal end oversizing (23%) than the group with no complications (17%) (P=0.0007). TEVAR for BTTAI shows good results in the long-term follow-up. Complications in our series seemed related to proximal end oversizing. Thoracic stent grafts with a smaller diameter should be available in all trauma centers to avoid excessive oversizing.

Nonoperative Management of Blunt Traumatic Thoracic Aortic Injury: Systematic Review and Meta–analysis of 3776 Patients

Nonoperative Management of Blunt Traumatic Thoracic Aortic Injury: Systematic Review and Meta–analysis of 3776 Patients

Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries.

Dear Editor, During the last decade, endovascular (EV) repair has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. The thoracic endovascular aortic repair (TEVAR) means percutaneous replacement of a stent within the descending thoracic or thoracoabdominal aorta to treat aortic aneurysm (1). The thoracic endovascular aortic repair has the advantage of being a less invasive technique compared to the open surgical method of repairing, owing to the unique ability to insert the stent through a small incision. Because the incision is small, the patients who are operated by the TEVAR technique have minimal amounts of blood loss. Through the TEVAR method, prolonged cross clamping of aorta is not necessary. As a result, the incidence of renal, visceral and spinal ischemia is fewer than that in the standard open surgical repair technique (2). Studies show that the TEVAR reduces early mortality and paraplegia compared with the open surgical management. The risk of dependency to the mechanical respiratory ventilation is lower in the thoracic endovascular aortic repairmen. Unlike the traditional aortic repair, standard recovery after the TEVAR is remarkably straightforward. Patients, who have undergone the TEVAR, typically spend one night in hospital to be monitored although it has been suggested that the TEVAR can be performed as a same-day procedure. In 2005, the United States Foods and Drugs Administration (FDA) approved the pivotal trial of the TEVAR for treating the patients with thoracic aorta aneurysm (2). Certainly, blunt traumatic thoracic aortic injuries are among the most dangerous and fatal emergency situations. The typical mechanism causing these injuries is blunt deceleration, usually from motor vehicle collisions, falls, and crushes with significant amounts of force. So, the blunt traumatic thoracic aortic injuries occur in young patients with multiple traumas (3). Since the last decade, so important advancements have been developed in medical and surgical management of blunt traumatic thoracic aortic injuries. Endovascular stent graft technologies are employed increasingly as an off label emergency treatment of these kinds of aortic injuries (4, 5). Finally, as experiments, we present two cases of 23 and 25 year-old men, who were admitted to our hospital because of blunt traumatic thoracic aortic injuries from car accidents. They were operated by the TEVAR technique. The management of both patients was the same. First of all, a chest X-ray was performed. The widening of mediastinum was obvious on the X-ray (Figure 1). Figure 1. Preoperation CXR-widening of mediastinum is obvious in preoperation CXR. In the next step, Computed Tomography (CT) angiography and an aortography were done. This study confirms the dissection of descending thoracic aorta. The patients were underwent the repair of thoracic aorta by the EV stent insertion approach. At the end of surgery, after repairing the injured part of aorta, the patients were referred to Intensive Care Unit (ICU) in the surgery ward. They were closely observed for 3 days. After three days of hospitalization, they were discharged with acceptable conditions. As it is obvious, this minimally invasive EV approach results in several advantages for the patients compared with the open surgical repair. Therefore, it is highly recommended that the TEVAR be used instead of the open repair of blunt traumatic injury of the aorta.

Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury.

Blunt traumatic thoracic aortic injury (BTAI) is a life-threatening surgical emergency associated with mortality up to 8000 per year, most commonly caused by rapid acceleration/deceleration injury sustained through motor vehicle accident and/or blunt thoracic trauma. BTAI has high pre-hospital mortality following the primary injury, with only 10% to 15% of patients surviving long enough to reach the hospital. Open surgical repair had remained the standard treatment option for BTAI since successfully introduced in 1959. However, with technological advances, thoracic endovascular repair (TEVAR) offers an alternative treatment option for BTAI. TEVAR is a less invasive surgical approach for management of these already critical patients; many reports have described favourable early outcomes.Thoracic endovascular repair may appear to be superior to open repair for treatment of BTAI. However, its long-term results and efficacy remain unknown. No randomised controlled trials (RCTs) have provided evidence to support the superiority of the endovascular approach versus open repair in the treatment of BTAI. This review aims to address this matter. To determine whether use of TEVAR for treatment of BTAI is associated with reduced mortality and morbidity when compared with conventional open surgery. The Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 7) and clinical trials databases for details of ongoing and unpublished studies. We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI. Two review authors independently reviewed all RCTs identified by the Trials Search Co-ordinator. We found no RCTs that met the inclusion criteria for this review. We found no RCTs conducted to determine whether use of TEVAR for the treatment of BTAI is associated with reduced mortality and morbidity when compared to conventional open repair. Hence, we are unable to provide any evidence to guide the treatment option for this life-threatening condition. To perform a randomised controlled trial to clarify the optimal management of BTAI would be highly challenging due to the natural history of the condition. Despite the lack of RCT evidence, clinicians are moving forward with endovascular treatment of BTAI on the basis of meta-analyses and large clinical series.

Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome From Four Tertiary Referral Centers

To analyze the early and long-term survival and re-intervention rate in patients undergoing TEVAR for blunt traumatic thoracic aortic injury.

Predictors of Discharge Home after Blunt Traumatic Thoracic Aortic Injury

Blunt traumatic thoracic aortic injury (BTAI) can be a highly lethal injury but in the last decade major advances have been made in diagnostic accuracy, injury grading, and therapy. Traditionally, emphasis has been on studying survival postinjury with a paucity of studies examining the discharge characteristics of patients that survive a BTAI. The purpose of this study is to define the epidemiology and predictors of disposition in patients with BTAI in a provincial database. Using the Ontario Trauma Registry, all patients were identified who were hospitalized with a BTAI between 1999 and 2009. Trends in therapy and discharge disposition were determined. We identified 264 cases of BTAI. Of these, 157 were discharged from hospital with 36% (n = 56) going directly home and 64% (n = 101) going to continuing care facilities. There was no difference in disposition in those with BTAI treated operatively or nonoperatively (P = 0.48). In those that had repair of BTAI, there was no difference in discharge home between open and endovascular repair (P = 1.00). Univariate analyses identified younger age, male sex, lower injury severity score (ISS), and lower Charlson comorbidity indices as being predictors of discharge home. On adjusted multivariate regression analysis, lower ISS (odds ratio, 0.91; 95% confidence interval, 0.87-0.95; P < 0.001) was the only independent predictors of discharge home. Our findings suggest that the only independent predictor for discharge home for patients who survive is the overall severity of all their injuries irrespective of their condition on admission or management of their BTAI.

Editor's Choice – Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers

To analyze the early and long-term survival and re-intervention rate in patients undergoing TEVAR for blunt traumatic thoracic aortic injury. This was a consecutive case series. Between the years 2001 and 2010, a total of 74 patients underwent TEVAR for blunt traumatic thoracic aortic injury at four tertiary referral centers, three in Sweden and one in Switzerland. The median age of the patients was 41 years, and 16% were women. Demographic, procedural, and outcome data were collected and reviewed retrospectively. The patients were followed up during 2013-2014. Early (30 day) mortality was 9% (7 patients), with only two cases directly related to the aortic injury; in hospital mortality was 14% as three patients died during the primary hospital admission within the first 6 months. Most patients had sustained severe injuries to other organ systems, and among all in hospital deaths brain injury was the predominant cause. Five year survival in the whole group was 81%. Re-intervention was needed in 16% (12 patients) during the first year, half of them within the first month. Only one patient underwent re-intervention more than 1 year after the initial procedure. Infolding and partial stentgraft collapse was the reason for the secondary procedure in five of the 13 patients; in three it occurred within 3 weeks of the acute TEVAR. TEVAR allows rapid and effective therapy in trauma patients with blunt aortic injury. The outcome is dependent on the severity of the concomitant injuries. The treatment is durable during the first decade after the procedure, but even longer follow up is needed to determine the impact of TEVAR in young patients on the degenerative changes that take place in the aging aorta.

Management of Blunt Traumatic Thoracic Aortic Injuries Compared With Clinical Practice Guidelines

Management of Blunt Traumatic Thoracic Aortic Injuries Compared With Clinical Practice Guidelines

Durability of TEVAR in Blunt Traumatic Thoracic Aortic Injury – Long-term Experience from Two Tertiary Referral Centres

Durability of TEVAR in Blunt Traumatic Thoracic Aortic Injury – Long-term Experience from Two Tertiary Referral Centres

Female Sex Is Associated with a Lower Risk of Stroke in Patients with Heart Failure: A Nationwide Cohort Study

Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications.We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender.We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I2 = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I2 = 52%; P = .03), 0% (95% CI, 0%-2.0%; I2 = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I2 = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I2 = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I2 = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I2 = 65%; P < .01), 0% (95% CI, 0%-1.8%; I2 = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I2 = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I2 = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (β = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (β = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (β = .54; 95% CI, 0.3-0.90).This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

Delayed Management of Blunt Traumatic Aortic Injury: Open Surgical Versus Endovascular Repair

A growing body of evidence has shown that delayed management of traumatic injury of the thoracic aorta determines survival benefits as compared with immediate treatment. However, few data exist comparing outcomes after delayed open surgical or endovascular management. Accordingly, we reviewed our experience with delayed management, stratifying the data according to type of repair; open surgical versus endovascular. Since 1992, delayed aortic repair has represented our first-line management for all blunt traumatic thoracic aortic injury (BTTAI) patients, except for those who presented with or became unstable due to impending aortic rupture. These patients were converted to urgent primary aortic repair. Thus, between 1992 and 2010, a total of 77 BTTAI patients were managed according to this policy. There were 57 (74%) men having amean age of 33.4 years. Thirty-one (41.3%) patients underwent open surgical repair (SR), 44 (58.6%) underwent endovascular repair (ER), and 2 died while awaiting aortic repair. At admission, the clinical and trauma characteristics were similar in both groups. The trauma-to-repair time span (in days) was 200 (Q1-Q3: 27 to 340) and 10 (Q1-Q3: 2 to 79) for SR and ER patients, respectively (p= 0.001). Due to unpaired hemodynamic or imaging signs of impending aortic rupture, 15 patients required urgent repair, which was endovascular in 11 (25%) cases and surgical in 4 (12.9%). Overall, hospital mortality was 3.9% (n= 3), being 0% in SR patients and 2.3% (n= 1) in ER patients (p= 0.398). No new postoperative paraplegia occurred; a cerebellar stroke occurred in 1 (2.3%) ER patient receiving intentional coverage of the left subclavian artery. During follow-up (96.1% complete at 95 ± 70 months), no late deaths occurred. At 15 years, the estimates of survival and freedom from secondary aortic procedures were 96% and 100%, respectively. Delayed management of traumatic aortic injury was associated with satisfactory short- and long-term results without significant differences between open surgical and endovascular repair. However, the reduced invasiveness of endovascular repair can optimize operative timing allowing prompt aortic repair in unstable patients, earlier repair in stable patients, and, when indicated, easier concomitant non-aortic surgery.

Significance of computed tomography in morphological classification of blunt traumatic thoracic aortic injury

Objective To discuss imaging classification of blunt traumatic thoracic aortic injury (BTTAI) and weigh guideline value of its imaging classification to surgical options.Methods BTTAI in 12 patients were divided into three types in accordance with outline of aortic injury revealed by CT imaging,i.e.,type A of normal outline of aortic blood vessel but free endothelium in aortic cavity,type B of abnormal aortic outline and contrast extravasation to aortic lumen exterior but only confining to mediastina,and type C of abnormal aortic outline and contrast leakage to thoracic cavity.Significance of BTTAI morphological classification was analyzed according to data,such as systemic injury severity score (ISS),local injury sites,surgical approaches and patients' outcome.Results Multiple injuries combined with BTTAI were observed in all patients whose aortic lesion image could be all generalized by above-mentioned classification.BTTAI image showed type A in three patients,type B in seven and type C in two.Pseudoaneurysm was confirmed as the foremost common BTTAI.There were no significant differences in ISS,hypotension morbidity,treatment methods or mortality between each type of BTTAI.Conclusions BTTAI occurs mostly in multiple injuries and thus overall injury severity assessment is not only depended on aortic lesion classification.BTTAI classification in this study reflects injury severity of vessel wall,takes account to location of lesion and adjacent relations (especially length of landing zone) and hence has accurate referential value for surgical decisions. Key words: Thoracic injuries; Aorta, thoracic ; Cardiac imaging techniques