Free Rupture Research Articles

Erosion of a right ventricular pacer lead into the left chest wall

BackgroundErosion of a pacer lead into the chest wall may result in pericardial effusion with cardiac tamponade. Free rupture into the pleura or mediastinum can result in hypotension and cardiac arrest.Case presentationWe report a unique case of a right ventricular pacer lead which eroded through the right ventricle into the left chest wall and penetrated a rib. The patient presented with a tender chest wall mass without pericardial or pleural effusion. The segment of rib which the pacing lead had penetrated was removed.ConclusionsThe patient tolerated the procedure well and was discharged 1 week after the operation. This case adds to the current literature the justification of removal of temporary and non-functional pacing leads.

P1722 Post myocardial infarction pericarditis or subacute left ventricular free wall rupture after acute myocardial infarction- a role of multimodality imaging

Abstract Introduction Moderate to severe pericardial effusion (PE) in patients with acute myocardial infarction (AMI) can be associated with a broad spectrum of etiologies like left ventricular free wall rupture (LVFWR) or post- myocardial infarction pericarditis (PMIP). We present a case of successful medical treatment of patient with subacute LVFWR after AMI, initially managed as PMIP. Case Presentation A 60- year- old man with a history of hypertension was admitted with persisting chest pain for 72 hours, with diagnosis of ST- segment elevation AMI of inferior wall. Patient underwent a percutaneous coronary intervention (PCI) of the right coronary artery as the AMI culprit vessel. Two days after PCI patient experienced progressive sharp chest pain, dyspnea and low- grade fever. Clinical evaluation revealed elevated inflammatory markers and pericardial rub. Transthoracic echocardiography (TTE) showed PE up to 10 mm. Patient has been diagnosed and treated as PMIP. During further observation patient had TTE performed repeatedly. Four days after PCI TTE revealed PE of 20 mm thickness and suspicion of subacute LVFWR of the lateral wall. Cardiac magnetic resonance (CMR) confirmed the diagnosis. Due to hemodynamic stability, the patient received only medical treatment. During further hospitalization TTE was performed every day. On fifteenth day both TTE and CMR didn’t reveal any rupture. Moreover patient was readmitted 6 weeks after initial hospitalization and TTE again did not show the LVFWR. Discussion Post AMI patients with PE who fulfill pericarditits diagnostic criteria should be managed as having PMIP. Nevertheless LVFWR should also be considered as frequent diagnosis of PE. Echocardiography is crucial in the prompt diagnosis of PE. In our presented case, the TTE did not show initially the LVFWR, only repeatedly performed investigation showed the increasing amount of PE and raised suspicion of subacute LVFWR, which was confirmed in CMR. CMR has become a tool providing accurate diagnosis and visualization of the localization of rupture. Moreover CMR imaging can show LVFWR revealing whether the hematoma is circumscribed to the myocardium or communicates with ventricular cavity or the pericardial sac. LVFWR is a catastrophic complication accounting for a significant proportion of in-patient deaths. It is accepted that emergent surgical repair is the cornerstone treatment for patients with LVFWR. However, similarly to ours, some cases with fairly good survival rates following isolated medical treatment have been reported. This clinical situation stands somewhere between the insidious free rupture into the pericardial cavity and the formation of the pseudoaneurysm. Conclusions Our presentation illustrates the usefulness of repeated multimodality imaging for the diagnosis and follow up of patients with PE after AMI. Our case also underscores the value of a conservative approach as a valid alternative to surgery in some patients with subacute LVFWR.

P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography

Abstract 【Background】 Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare. 【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion. CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery. The postoperative course was good and he was discharged without any complications. 【Discussion】 False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture. We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space. We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case. Abstract P1480 Figure. Triple aneurysms

Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study

Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI. Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality. A total of 99 patients (54% men; mean age, 48years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90min and 11days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n=8) and stroke (n=2) were observed at 30days. Late stroke and paraplegia (>30days) were not observed during the mean 49±26months of follow-up (median, 48months; range, 0-117months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30days and 8% at 1year. The survival rate was 95% at 30days, 92% at 1year, 92% at 3years, and 89% at 5years. One type Ia endoleak occurred at 18months after the procedure. TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.

Brucella-Induced Ruptured Infrarenal Dissecting Abdominal Aortic Aneurysm.

Mycotic aneurysms, often saccular, accounting for approximately 2.5% of all abdominal aortic aneurysms, possess increased risk of rupture, uncontrolled sepsis, and protracted hospital stay and are associated with high morbidity and mortality. The authors report the case of a 49-year-old female with no known comorbidities who presented with free rupture of an infrarenal dissecting mycotic aneurysm and underwent emergent open repair successfully. The etiological agent, Brucella melitensis , a Gram-negative zoonotic coccobacillus, is rarely reported to cause mycotic aneurysm.

Pre-operative predictors of early recurrence/mortality including the role of inflammatory indices in patients undergoing partial hepatectomy for spontaneously ruptured hepatocellular carcinoma.

Spontaneous rupture of Hepatocellular Carcinoma (srHCC) is a life-threatening emergency. We sought to identify the pre-operative predictors of early tumor recurrence/mortality including the role of inflammatory indices after partial hepatectomy for srHCC. Between 2000-2015, 79 patients with srHCC were identified to have undergone upfront partial hepatectomy following srHCC. Clinicopathologic data were retrospectively analyzed to identify pre-operative predictors of early (<1 year) recurrence and mortality. Seventy-nine patients were identified to have undergone partial hepatectomy for srHCC. The 1-year mortality and 1-year recurrence rate in our series was 30.3% and 41.8% respectively. On multivariate analyses, free tumor rupture and a tumor size > 10 cm were identified to be independent predictors of early recurrence while an alpha fetoprotein (AFP) > 200 ng/mL was an independent predictor of early mortality. Neutrophil-to-lymphocyte ratio > 3 and prognostic nutritional index < 40 were predictors of early recurrence while PLR > 180 was a predictor of early mortality on univariate analyses but not multivariate analyses. Tumor size > 10 cm, free tumor rupture, and an AFP > 200 ng/mL were useful predictors in avoiding "futile surgery" in patients with srHCC undergoing a partial hepatectomy. Preoperative inflammatory markers appear to be less useful as predictors of early recurrence/mortality in this cohort of patients.

OC24 ENDOVASCULAR SURGERY FOR ACUTE THORACIC AORTIC SYNDROMES

Background and Aim: Surgery of thoracic aortic emergencies is challenging and carries significant high morbidity and mortality rate. In the last decade, Thoracic EndoVascular Aortic Repair (TEVAR) has shown improved early and late outcome, mostly in emergency. To assess early and long-term results after TEVAR for thoracic aortic emergencies we retrospectively reviewed our experience. Methods: From March 2001 to March 2018, out of 289 patients undergone TEVAR, we retrospectively reviewed 191 patients, 164 (85.9%) men; aged from 19 to 84 years, treated in urgent/emergent conditions: 51 patients (26.7%) for contained or free rupture of degenerative aneurysms, 118 (61.8%) for complicated acute or chronic type B aortic dissections and 22 (11.5%) for traumatic aortic injuries. Results: The overall 30 days mortality was 4.4% (8 patients). Open surgical conversion was not required.. Periprocedural complications included arterial rupture or dissection (5.7%; 11 patients) and TIA/stroke (1.6%; 3 patients). Left subclavian artery (LSA) overstenting was achieved in 79 patients (41.3%). Follow-up ranged from 2 to 204 months and included clinical examinations and serial CT-scan. There were 8 late deaths aorta-related (4.4%). A secondary endovascular procedure was required in 13 pts (7.1%). One patient (0.5%), with retrograde aortic dissection, required open surgery. No patient with LSA overstenting required a secondary revascularization or showed subclavian steal phenomenon. Conclusions: The early and mid-term technical and clinical results supports the safety and effectiveness of thoracic endovascular surgery in patients with acute aortic syndromes too. More cases and longer follow-up are required.

Ultrasound-guided percutaneous catheter drainage of various types of ruptured amebic liver abscess: a report of 117 cases from a highly endemic zone of India.

To determine the efficacy and safety ultrasound-guided percutaneous catheter drainage (US-PCD) in management of various types of ruptured amebic liver abscess including free rupture (FR) with diffuse intraperitoneal fluid collections (DIFC). This study analyzed 117 patients with ruptured ALA who underwent US-PCD. The indication for US-PCD was failure to respond to conservative treatment and/or percutaneous needle aspiration. Majority of patients were locally fermented alcohol abusers (95%), and malnourished (75%). Ninety-eight patients had intraperitoneal rupture including 66 contained rupture (CR) with localized intraperitoneal fluid collection (LIFC) and 32 FR with DIFC. Pleuropulmonary complication was found in 19 patients including 13 pleural and 6 pulmonary. A total of 333 catheters were used to drain 202 abscess cavities and associated fluid collections. US-PCD was technically and clinically successful in all cases. Multiple sessions (median 2; range 2-5) of PCD required with upsizing the catheter (median 14 F; range 14-20 F) and placement of additional catheter in 26 (22%) patients. The patients with FR with DIFC required more number of catheters (p = 0.01) and had longer hospital stay (p = 0.01). No major procedure related complication was observed. Six patients developed secondary bacterial infection; two of them presented with cavito-cutaneous fistula at catheter insertion site, and one with cholangitis due to biliary stricture formation necessitating subsequent endoscopic treatment. Post-procedural death occurred from sepsis in a patient with FR. US-PCD is a safe and effective mode of treatment for ruptured ALA including FR with DIFCs. We recommend PCD as a first-line therapy for ruptured ALA.

Probing the Binding Affinity by Jarzynski's Nonequilibrium Binding Free Energy and Rupture Time.

Binding affinity of a small ligand to a receptor is the important quantity in drug design, and it might be characterized by different quantities. The most popular one is the binding free energy, which can be estimated by several methods in conventional molecular dynamics simulation. So far in steered molecular dynamics (SMD), one can use either the rupture force or nonequilibrium pulling work as a measure for binding affinity. In this paper, we have shown that the nonequilibrium binding free energy Δ GneqJar, obtained by Jarzynski's equality at a finite pulling speed, has good correlation with experimental data on inhibition constants, implying that this quantity can be used as a good scoring function for binding affinity. A similar correlation has also been disclosed for binding and unbinding free energy barriers. Applying the SMD method to unbinding of 23 small compounds from the binding site of β-lactamase protein, a bacteria-produced enzyme, we have demonstrated that the rupture or unbinding time strongly correlates with experimental data with correlation level R ≈ 0.84. As follows from the Jarzynski's equality, the rupture time depends on the unbinding barrier exponentially. We show that Δ GneqJar, the rupture time, and binding and unbinding free energy barriers are good descriptors for binding affinity. Our observation may be useful for fast screening of potential leads as the SMD simulation is not time-consuming. On the basis of nonequilibrium simulation, we disclosed that, in agreement with the experiment, the binding time is much longer than the unbinding one.

Single-center mid-term experience with chimney-graft technique for the preservation of flow to the supra-aortic branches.

Objectives To investigate the feasibility and the mid-term outcomes of the chimney-graft technique for the revascularization of supra-aortic branches in patients with thoracic aortic pathologies involving the aortic arch. Methods A retrospective analysis of a prospectively maintained database between January 2010 and July 2016 was performed. Primary endpoints were 30-day and overall mortality. Secondary endpoints were technical success, target vessel patency, stroke/transitory ischemic attack and type I/III endoleak rate. Results A total of 30 patients (80% male, median age 70.0 years) were treated using the chimney-graft technique for the supra-aortic branches. The indication was a degenerative aneurysm in nine patients (32%) and a type B Stanford aortic dissection and a penetrating aortic ulcer in the descending aorta in seven patients (23%), respectively. In six patients (20.0%), the indication was an type Ia endoleak after previous endovascular thoracic repair, whereas a pseudoaneurysm after previous open repair of the descending aorta was the indication in one patient (3%). Twenty-three patients (77%) were treated electively, five (17%) emergently and two (7%) urgently because of free rupture. Technical success was achieved in 90% of patients. The 30-day/in-hospital mortality was 17% (5/30). A retrograde dissection was presented in five patients. Four patients experienced a cerebrovascular event. Eight patients had type Ia endoleak and 10 had type II. During the median follow-up of 16 months (range: 0-56), four further patients died: one in respiratory insufficiency, one due to a ruptured abdominal aortic aneurysm, one in meningitis and the last one for unknown reason. The chimney-graft patency was 100%. According to the Kaplan-Meier curve, the estimated survival at one year was 66 ± 9%. Conclusions The chimney-graft technique, despite a technically demanding strategy, is a useful tool as bailout procedure in our armamentarium for high-risk patients, unsuitable for open or hybrid repair.

Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries

ObjectiveThe natural history and parameters for successful nonoperative management of blunt traumatic aortic injuries (BTAIs) involving the descending aorta are poorly understood. We examined our experience with nonoperative BTAI treatment (anti-impulse, blood pressure) and evaluated for determinants of successful outcomes. MethodsWe performed a review of our institutional prospective trauma registry database for all BTAI patients from 1999 to 2015. Computed tomography angiography was used to classify aortic injuries on the basis of severity: grade I, intimal tear; grade II, intramural hematoma; grade III, aortic pseudoaneurysm; and grade IV, free rupture. Grade IV injuries were excluded from nonoperative management. Baseline characteristics, clinical outcomes, and follow-up lesion resolution were compared within the medically managed cohort and between surgical and nonoperative groups using univariate and multivariable analysis. ResultsAmong 338 BTAI patients admitted between 1999 and 2015, 67 BTAI patients were managed nonoperatively; 26 (54%) had grade I BTAI, 22 (46%) had grade II, and 2 (4%) had grade III. Both grade III injuries required a late thoracic endovascular aortic repair after initial medical management and were excluded from analysis. In all, 48 were managed with initial medical therapy, and the remaining 19 died on admission or before definitive treatment. Among the 48 medically managed, the median age was 34 years, and 14 (29%) were female. Six of the 48 (12%) were transferred from other facilities. There was no significant difference in baseline characteristics or early outcomes between BTAI grades. Median injury resolution time was 39 days for grade I and 62 days for grade II (P = .03). Compared with a surgical cohort, BTAI grade and Abbreviated Injury Scale score for the chest were the only significant determinants of propensity to operate. ConclusionsBased on these limited data, it appears that patients with minimal aortic injuries (grades I and II) may be managed medically, with the majority resolving within 8 weeks. Minimal aortic injury is associated with low mortality and excellent intermediate-term outcomes. Further prospective studies are required to validate these findings.

Determinants and Outcomes of Nonoperative Management of Blunt Traumatic Aortic Injuries

Natural history and parameters for successful nonoperative management of blunt traumatic aortic injuries (BTAIs) are poorly understood. We examined our experience with nonoperative BTAI treatment (anti-impulse, blood pressure) and evaluated for determinants of successful outcomes. Review of trauma registry database for all patients with BTAIs from 2004 to 2015 was performed. Computed tomographic angiography was used to classify aortic injuries: grade 1, intimal tear; grade 2, intramural hematoma; grade 3; aortic pseudoaneurysm; and grade 4, free rupture. Grade 4 injures were excluded from nonoperative management. Baseline, clinical outcomes, and follow-up lesion resolution were compared within the medically managed cohort and between surgical and nonoperative groups using univariate and multivariable analysis. Among 338 patients with BTAI admitted between 2004 and 2015, 67 patients with BTAIs were managed nonoperatively, 48 were managed with initial medical therapy, and the remaining 19 died on admission or prior to definitive treatment (Fig 1). Among the 48 medically managed, median age was 34 years, and 13 (27%) were female. Six of 48 (12%) were transferred from other facilities. Twenty-five (52%) had grade 1 BTAI, 21(44%) had grade 2, and two (4%) had grade 3. No baseline or early outcomes were significantly different between BTAI grades. Median injury resolution time was 39 days in grade 1 and 62 days for grade 2 (P = .09; Fig 2). Both grade 3 injuries required a late thoracic endovascular aneurysm repair following initial medical management. When compared with a surgical cohort, BTAI grade and Abbreviated Injury Scale (AIS) chest were the only significant determinants of propensity to operate. Based on this limited data, it appears that grade 1 and 2 injuries may be managed medically with the majority resolving within 8 weeks. Minimal aortic injury is associated with low mortality and excellent intermediate-term outcomes. Further prospective studies are required to validate these findings.Fig 2Cumulative healing rate by injury grade.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mortality Risk for Ruptured Abdominal Aortic Aneurysm in Women

Sex differences in presentation and outcomes of abdominal aortic aneurysms (AAA) with increased mortality rates in women are suggested. This study aimed to assess mortality risk after repair of ruptured AAA (rAAA) in women in the endovascular abdominal aortic repair (EVAR) era. Patients treated between 2006 and 2015 for rAAA were included in a prospective database. Characteristics at presentation and outcomes were compared between women and men. Multivariable logistic regression and Cox proportional analyses were performed to identify the effect of sex adjusted for other predictors on mortality. One hundred thirteen patients were identified; of these, 17.7% (20/113) of the patients were women. Forty-four procedures (38.9%) were by EVAR, with comparable rates in women (45%) and men (37.6%, P=0.62). On admission, women and men shared similar comorbidities and presentation (shock 45% vs. 43.0%, P=0.81; free rupture 65.0% vs. 67.7%, P=0.80) and comparable mean aneurysm diameter (76.5 vs. 78.8mm, P=0.68), but women were older (mean age 86.4+5.5 vs. 75.2±10.6years, P<0.0001) and octogenarian women were twice as likely as men (90% vs. 40%, P<0.0001). Perioperative mortality was comparable between women and men (40.0% vs. 38.7%) either after EVAR (22.2% vs. 40.0% in women and men respectively; odds ratio [OR] 0.45, 95% confidence interval [CI] 0.77-2.37) or after open surgery (54.5% vs. 37.9%; OR 2.0, 95% CI 0.54-7.21), even though there was a trend for lower mortality in women with EVAR. In adjusted analyses, female sex was not associated with perioperative mortality as it was for older age (octogenarians: OR 6.6, 95% CI 2.08-20.82, P=0.001) and free rupture (OR 4.2, 95% CI 1.29-13.73, P=0.02). Mean follow-up was 34.32months. After controlling for age, surgical repair, free rupture, cardiac disease, and shock at presentation, female sex was not a predictor of late mortality. AAA repair is often delayed in women and applied at older age; nevertheless, currently women do not show increased perioperative mortality risks from rAAA treatment after the introduction of EVAR.

Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms in a Chinese Population

The aim of this study was to compare the perioperative outcomes and midterm survival rate between open surgical repair (OSR) and endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) in a Chinese population. A retrospective review was performed of the demographic characteristics and perioperative outcomes from 59 RAAA patients (mean 66.6±13.3years of age; 49 men) undergoing OSR or EVAR at our center between January 2003 and November 2014. The perioperative mortality and midterm survival were assessed and compared between the OSR and EVAR groups. Twenty-three patients underwent OSR, and 36 patients underwent EVAR. The overall 30-day mortality was 36.5% (47.8% OSR vs. 27.8% EVAR, P=0.14). Total surgical time, estimated blood loss, and blood transfusion in the OSR group were significantly greater than those in the EVAR group (P<0.001). Reintervention within 30days and during the follow-up was more frequent in the EVAR group (36.1%) than in the OSR group (8.7%, P=0.026). The mean follow-up was 38.2±29.3months (range 6-100). A Kaplan-Meier survival curve analysis showed no significant difference between the 2 groups (P=0.079). The overall survival rate at 1year was 52.5% (31/59). Univariate and multivariate logistic regression analyses demonstrated that free intraperitoneal rupture (odds ratio [OR] 0.143, 95% confidence interval [CI] 0.030-0.694, P=0.016) and cardiovascular disease (OR 0.072, 95% CI 0.006-0.898, P=0.041) were independent risk factors for the 30-day mortality. Only intraperitoneal rupture was associated with the higher midterm mortality (OR 4.852, 95% CI 1.046-22.499, P=0.044). In an experienced vascular center in China, although the 30-day mortality and midterm survival of RAAAs were not significantly different between the EVAR and OSR groups, EVAR has superior perioperative advantages. Consequently, EVAR is recommended as the first-line treatment for anatomically suitable RAAA.

PC170. Management Challenges in Patients With Blunt Abdominal Aortic Injuries

Blunt abdominal aortic injuries (BAAI) are rare, accounting for only 5% of all blunt aortic traumas. We reviewed the incidence, management, and outcomes of patients with BAAI at a Level I urban trauma center over a 10-year period. Through our trauma registry, we retrospectively reviewed all patients who presented with BAAI to a Level I urban trauma center from 2004 to 2014. Medical records and autopsy data were used to analyze the severity and location of aortic trauma, associated injuries, treatment methods, and outcomes. We identified 38 total patients with blunt aortic injuries. Blunt thoracic aortic trauma accounted for 85% of the injuries. BAAI were identified in 6 patients (15%). The median age of BAAI patients was 41 years (range, 29-82 years). Motor vehicle collision was the etiology in 4 patients and pedestrian struck in 2 patients. Median injury severity score (ISS) was 66.5 (range, 34-75). There were 5 injuries of the infrarenal aorta (2 intimal tears, 1 dissection, 1 pseudoaneurysm, 1 free rupture) and 1 free rupture at the level of the left renal artery. All patients sustained additional spine or other bony fractures. There were 11 associated solid organ and bowel injuries in 4 patients. In-hospital mortality was 50%, which included both free ruptures and one case of infrarenal aortic dissection in the setting of brain death. Laparotomy and repair of an aortic tear at the level of the left renal artery was performed on one free aortic rupture, with a hospital course complicated by multiple organ resections, intra-abdominal sepsis, and death secondary to aortic rupture 8 days after initial repair. The patient with the infrarenal aortic pseudoaneurysm was treated with aortic stent graft cuffs, with survival to discharge after a course complicated by respiratory failure from lung injuries. Two patients with intimal tears were managed nonoperatively to discharge. Two of the survivors were found to be isolated blunt abdominal aortic traumas, without concomitant intra-abdominal injuries, while the third survivor sustained additional blunt gastric, small bowel, and colon injuries. In contrast, both free aortic ruptures were associated with multiple solid organ and bowel injuries. BAAIs are rare events with high mortality rates. Management decisions are challenging and must be made in the setting of complex injuries across multiple systems.

Arbitrary Palliation of Ruptured Abdominal Aortic Aneurysms in the Elderly is no Longer Warranted

A consistent number of elderly patients with ruptured abdominal aortic aneurysms (rAAAs) are deemed unfit for repair and excluded from any treatment. The objective of this study was to examine the impact on survival of endovascular repair and open surgery with restricted turndown in acute AAA repair. A prospective database for patients treated for rAAA was established. None of the patients admitted alive with rAAA were denied treatment. Multivariate regression models, the predictive risk assessment Glasgow Aneurysm Score (GAS), and subgroup analyses in older patients were applied to identify indicators of excessive 30 day mortality risk that could affect the decision for turndown. From 2006 to 2015, 113 consecutive patients (93 males; mean age 77.2 years) with rAAAs were treated (69 open surgery; 44 EVAR). Overall peri-operative (30 day) mortality was 38.9% (44/113): 40.6% (28/69), and 36.4% (16/44) after open surgery and EVAR, respectively (p=.70). Multivariate logistic regression identified old age as an indicator of increased peri-operative mortality (odd ratio [OR] 1.2, 95% confidence interval [CI] 1.1-1.3; p=.001), as well as free aneurysm rupture (OR 5.0, 95% CI 1.3-19.9; p=.02). GAS was higher in patients who died (97.75 vs. 86.62), but the score failed to identify increased peri-operative mortality risk in adjusted analyses (OR 1.0; p=.06). Almost two thirds of the patients (n=71) were older than 75 at the time of aneurysm rupture (48.6% octogenarians) and EVAR was more commonly applied than open surgery (86.4% vs. 47.8%; p<.0001). Peri-operative mortality in > 75 year old patients was 46.5% compared with 26.2% in younger patients (p=.05), with rates increased after open surgery (54.5% vs. 27.8%, p=.03) but not after EVAR (39.5% vs. 16.7%; p=.39). According to Kaplan-Meier estimates, mean survival was 39.7±4.8 months. Patients older than 75 years of age survived for a mean of 23.0±4.47 months after rupture. In this study aggressive treatment with a very restricted or no turndown strategy for any rAAA, also applied to older patients, allowed for an additional mean 40 months of survival after aneurysm rupture. In the contemporary endovascular era the decision to deny repair arbitrarily to older patients with rAAAs must be revisited.

Injury grade is a predictor of aortic-related death among patients with blunt thoracic aortic injury

The current Society for Vascular Surgery Clinical Practice Guidelines suggest urgent (<24hours) thoracic endovascular aortic repair for grade (G) II to G IV blunt thoracic aortic injuries (BTAIs). The purpose of this study was to determine whether some patients may require more emergency treatment. We reviewed imaging variables of prospectively collected BTAI patients between 1999 and 2014. We used computed tomographic angiography to classify BTAIs into four categories: G I, intimal tear; G II, intramural hematoma; G III, aortic pseudoaneurysm; and G IV, free rupture. Specific examination of G III injuries was undertaken in an effort to predict aortic-related mortality (ARM) before repair. For this subset, we examined pseudoaneurysm size, lesion/normal aortic diameter ratio, and mediastinal hematoma location and size. Among 331 patients with BTAIs, 86 died before imaging. Admission computed tomographic angiography was available for 205 patients (71.2% male; mean age, 39.3years) with BTAIs (24G I, 49G II, 124G III, 8G IV). The mean Injury Severity Score was 35.6, and 22.4% had hypotension (<90mm Hg). Overall mortality was 11.2% (G I/G II, 4.1%; G III/G IV, 15.3%; P= .02). ARM was 2.4% (G I/G II, 0%; G III/G IV, 3.8%; P= .09). ARM was significantly greater in G IV (3 of 8 [37.5%]) than G III (2 of 124 [1.6%]) vs G I/II (0 of 73 [0%]) injuries (P< .0001). Medical management alone was used in 53 (20G I, 18G II, 13G III, and 2G IV). Open repair was performed in 51 (3G I, 9G II, 36G III, and 3G IV) at a mean time to repair (TTR) of 10.6hours. Thoracic endovascular aortic repair was conducted for 101 patients (1G I, 22G II, 75G III, and 3G IV) at a mean TTR of 9.4hours. Median TTR for the overall population of BTAI patients was 24.0hours from admission. (G I, 64.5hours; G II, 24.0hours; G III, 19.7hours; and G IV, 3.5hours). ARM occurred in four of five patients before planned repair (2G III and 2G IV), 7.0± 3.6hours from admission. No G I/II ARM occurred. Among eight G IV injuries, there were three ARMs. Focus on G III injuries through regression analysis demonstrated that early clinical/imaging variables (eg, mediastinal hematoma dimensions and lesion/normal aortic diameter ratio) were not significant predictors of ARM. Injury grade is a predictor of ARM among patients with BTAIs. Aggressive use of the current Society for Vascular Surgery Clinical Practice Guidelines at a busy level I trauma center resulted in low rates of ARM. In this setting, identification of additional physiologic and radiographic criteria indicating the need for emergency (vs urgent) repair of aortic pseudoaneurysms remains elusive.

Cardiac Contusions

Cardiac contusion has been one of the most discussed topics in the trauma community. The discussions are centered around appropriate nomenclature, screening mechanisms, diagnostic modalities, and ultimately management principles. Controversy over nomenclature exists because cardiac contusion has been used to describe an array of injuries ranging from a transient arrhythmia to free rupture of the myocardial wall. The mainstays of screening have been electrocardiograms and cardiac isoenzymes. Although there is a substantial body of literature, few other screening or diagnostic modalities have been widely accepted. Echocardiography has gained favor as a confirmatory test and to determine presence or extinct of structural damage. Management has traditionally been supportive including volume repletion, correcting arrhythmias, and repairing structural damage. Recently, there has been some promising alternative treatments including transcatheter closure of ventricular septal defects, anti-inflammatory agents, and post-injury therapeutic hypothermia. Although screening and diagnostic mechanism have remained relatively unchanged, it appears that innovative management of severe cardiac contusions has gained some momentum over the recent years.

НаружНый разрыв сердца и тромболитическая терапия. клиНическое НаблюдеНие

НаружНый разрыв сердца и тромболитическая терапия. клиНическое НаблюдеНие

Blunt abdominal aortic injury: a Western Trauma Association multicenter study.

Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6-88; median Injury Severity Score [ISS], 34; range, 16-75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. Epidemiologic study, level III; therapeutic study, level IV.