Thoracic Artery Injury Research Articles

Chest Compression-Associated Internal Thoracic Artery Injury During Cardiopulmonary Resuscitation: Incidence, Injury Patterns and Efficacy of Transcatheter Arterial Embolization.

To investigate the incidence and patterns of chest compression-associated internal thoracic artery injury (CAI) during cardiopulmonary resuscitation and identify the embolization techniques used to treat hemorrhage. A retrospective study was conducted in the patients who underwent transcatheter arterial embolization (TAE) for life-threatening hemorrhage caused by CAI at two tertiary care centers between May 2013 and December 2019. Data on background characteristics, imaging findings, embolization and outcomes were collected from the medical records. Among 385 patients in whom circulation returned after resuscitation, there were 9 patients (2.3%) who required TAE for CAI. Eight of 9 patients had acute myocardial infarction, and all had been started on extracorporeal membrane oxygenation before TAE. Seven patients had unilateral, and two had bilateral internal thoracic artery injuries. Main trunk injury of internal thoracic artery was seen in 27%, while branch injury in 73%. Six patients (67%) had multiple injuries in the internal thoracic artery territory, and five (56%) had injuries to other vessels. In all cases, we embolized the main trunk of the internal thoracic artery using n-butyl 2-cyanoacrylate and coils (n = 8), a gelatin sponge only (n = 2), or coils and a gelatin sponge (n = 1). TAE was technically successful in all, without any complication. The 30-day mortality rate was 44%. CAI needing hemostatic intervention occurred in 2.3% of patients after successful cardiopulmonary resuscitation. Branch injury was more common than main trunk injury, and multiple vessel injuries were common. TAE appears to be safe and effective for controlling life-threatening hemorrhage.

CT angiography of non-aortic thoracic arterial trauma.

While aortic injury is the most commonly cited thoracic arterial injury, non-aortic arterial injuries represent an uncommon but significant source of morbidity and mortality in blunt and penetrating thoracic trauma patients. Knowledge of the spectrum of vascular injury and anatomic considerations that dictate patterns of associated thoracic hemorrhage will assist the radiologist in the accurate and efficient diagnosis of these injuries. This article provides a review of anatomy, pertinent clinical exam and CT angiography findings, as well as therapeutic options for non-aortic thoracic arterial trauma.

Displaced sternal fracture and right internal thoracic artery injury induced by blunt chest trauma from cow kick.

Displaced sternal fracture and right internal thoracic artery injury induced by blunt chest trauma from cow kick.

Traumatic injury to the great vessels of the chest.

This manuscript undertakes a brief focussed literature review of penetrating and blunt injury to the great vessels of the mediastinum (excluding iatrogenic vessel injury) and provides personal insights to the management of mediastinal vascular injury. It is not intended as a comprehensive or systematic review. Included are the aorta and its main branches, the superior vena-cava and its main tributaries (brachiocephalic veins) along with the less-appreciated, but equally serious, injuries to the pulmonary artery or vein and the Azygous or hemi-azygous veins. An overview of the epidemiology of these injuries is provided. The gross anatomy is briefly reviewed from the perspective of the surgeon., Practical diagnostic approaches, using an algorithm, operative access and repair options, along with endovascular considerations are briefly highlighted. The detail of the operative procedures will highlight practical points for concern and local tips-and-tricks. Practical take-home messages are provided from the personal perspective of the authors. This overview does not cover intercostal vessel or internal thoracic artery injury, both of which may cause significant bleeding and cardiac tamponade in the case of the latter vessel, but technically are outside the central mediastinum and are branches of great vessels and are therefore not included.

Endovascular Repair with a Peripheral Vascular Stent Graft for Subclavian and Other Thoracic Arterial Injury

Endovascular Repair with a Peripheral Vascular Stent Graft for Subclavian and Other Thoracic Arterial Injury

Impact of trauma center volume on major vascular injury: An analysis of the National Trauma Data Bank (NTDB)

BackgroundThe association of procedure volume and improved outcomes has been established with infrequently performed elective operations. However, effect of trauma center volume on outcomes in emergency surgery has not been defined. We hypothesized that high volume centers (HVC) would provide better outcomes for operative major vascular injuries (MVI) than low volume centers (LVC). MethodsThe NTDB was queried from 2010 to 2014. Patients with MVI were identified and HVC were compared to LVC. HVC were defined as >480 patients per year with ISS≥15. ResultsThere were 37,125 patients with MVI, with 16,461 (44.3%) managed operatively. Of these, 15,965 (97%) underwent surgery at HVC and 496 (3%) at LVC. There was no difference in shunt utilization, however, HVC were more likely to utilize endovascular repair (31.0% vs. 21.9%, p < 0.001). Rates of death, amputation, and compartment syndrome were similar. HVC were more likely to develop pneumonia or sepsis. On logistic regression, HVC was not associated with survival (OR: 0.90, 95%CI: 0.60–1.34, p = 0.60). Variables associated with mortality for HVC and LVC included thoracic arterial injury (OR: 1.57, 95%CI: 1.27–1.94, p < 0.001), penetrating mechanism (OR:1.84, 95%CI: 1.57–2.15, p < 0.001), and open repair (OR: 1.95, 95%CI: 1.69–2.26, p < 0.001). Lower ISS (OR: 0.29, 95%CI: 0.24–0.34, p < 0.001) and higher presenting blood pressure (OR: 0.99, 95%CI: 0.99–1.00, p < 0.001) were associated with survival. ConclusionsAlthough LVC may have less proficiency with endovascular techniques, trauma center volume does not influence survival in emergency surgery for MVI.

2 cases of lateral thoracic artery injury after thoracic drainage

2 cases of lateral thoracic artery injury after thoracic drainage

The no-touch saphenous vein graft in elderly coronary bypass patients with multiple comorbidities is a promising conduit to substitute the left internal thoracic artery

ObjectivesWe investigated the patency rates of no-touch saphenous vein grafts anastomosed to the left anterior descending artery compared with the left internal thoracic artery. Further, we compared the patency of no-touch vein grafts to the left anterior descending artery with the patency of no-touch vein grafts to other coronary arteries. MethodsOf 2635 consecutive patients undergoing coronary artery bypass grafting between 2003 and 2008, 168 (6.3%) were given at least a saphenous vein graft to the left anterior descending artery to avoid harvesting complications in high-risk patients or in response to a left internal thoracic artery injury. A total of 97 patients were consecutively included after informed consent. A clinical examination and computed tomography angiography were performed on 91 patients at a mean of 6 (4-9) years. ResultsThe mean age of patients was 75.6 ± 8.5 years. Postoperatively, 88.7% of patients (86/97) were free of angina. The 91 examined patients had 163 grafts with 286 distal anastomoses. Crude patency, according to distal anastomoses, was 94.4% (270/286). The patency of single versus sequential no-touch vein grafts to the left anterior descending artery was 98% (50/51) versus 92.5% (37/40). The total patency rate was 95.6% (87/91), similar to the reported patency rate for the left internal thoracic artery. The no-touch grafts to the left anterior descending artery versus other coronaries had a patency of 95.6% (87/91) versus 93.8% (183/195), a high similarity confirmed by an equivalence analysis. ConclusionsIn elderly coronary bypass patients with multiple comorbidities, a no-touch saphenous vein graft is a promising substitute for the left internal thoracic artery.

Emergency Thoracotomy- Isolated Internal Thoracic Artery Injury

Aim: A tension haemothorax is an uncommon injury after penetrating chest trauma. Introduction: Anterior thoracic penetrating injuries may result in life-threatening complications. One of these is massive tension haemothorax with pericardial tamponade as a result of stab wounds to the internal mammary artery. Presentation of a Case: We present a case in which a 55 year old man sustained multiple thoracic stab wounds. He had emergency right antero-lateral thoracotomy and laparotomy. A massive haemothorax secondary to complete disruption of right internal mammary artery and a laceration to middle lobe of right lung was noticed. Conclusion: Penetrating thoracic injury with isolated internal mammary injury is a very rare cause of massive haemothorax and associated with high mortality. Emergent thoracotomy can be life-saving for these patients.

二次救急医療施設におけるJATECのprimary surveyが効を奏した刺創による内胸動脈損傷の1救命例

二次救急医療施設におけるJATECのprimary surveyが効を奏した刺創による内胸動脈損傷の1救命例

穿通性内胸動脈損傷の2例―胸腔鏡下手術と経皮的動脈塞栓術―

穿通性内胸動脈損傷の2例―胸腔鏡下手術と経皮的動脈塞栓術―

Is totally endoscopic coronary artery bypass safe, feasible and effective?

A best evidence topic was written according to a structured protocol. The question addressed was whether totally endoscopic coronary artery bypass (TECAB) is safe, effective and feasible. A total of 171 papers were found, of which eight represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The da Vinci robotic system was utilized in seven retrospective studies and one multicentre prospective trial, comprising 724 patients undergoing TECAB. Patient-related outcomes, including the incidence of major adverse cardiac events, graft patency and survival, were investigated. From the studies evaluated, TECAB appears to be safe operation with low complication rates and excellent early- and mid-term graft patencies. The incidence of internal thoracic artery injury was documented in four studies and ranged from 0 to 10%. Re-exploration for bleeding was necessary in 1-15% of patients. Conversion to open techniques was performed in 0-24% of cases. There was no in-hospital mortality in the majority of studies, but this reached 2.1% in a large series of 228 patients. Target-vessel reintervention rates varied between 0 and 12.1% according to the institutional experience. Pre- and post-discharge graft patencies were excellent at 93-100 and 92-100%, respectively. Intraoperative variables, such as time taken for internal thoracic artery harvest, anastomosis, cross-clamp, cardiopulmonary bypass (CPB) and the overall operation were as follows: internal thoracic artery harvest time (range 5-187 min), anastomosis time (range 6-82 min), cross-clamp time (range 30-223 min), CPB time (range 41-268 min) and operative time (range 84-600 min). TECAB is a technically demanding and time-consuming procedure associated with a significant learning curve. Proctoring and structured training programmes are currently supported by European and international societies to encourage wider uptake of the procedure. In conclusion, TECAB represents a feasible alternative to conventional coronary artery bypass in selected patients. It is associated with low morbidity and excellent mid-term graft patency. Larger, prospective and multicentre trials are required to assess the long-term and patient-reported outcomes of TECAB.

Transcutaneous aortic valve implantation using the axillary/subclavian access with patent left internal thoracic artery to left anterior descending artery: Feasibility and early clinical outcomes

Both retrograde femoral and subclavian artery catheterization techniques have been described as the most common methods for the implantation of the Medtronic CoreValve percutaneous aortic valve (Medtronic Inc, Minneapolis, Minn). The subclavian artery has been shown to be a safe and effective alternative access route in patients with unfavorable femoral access. Of the patients who are identified as candidates for subclavian artery access, a subset possess a patent left internal thoracic artery to left anterior descending artery. This patent left internal thoracic artery presents an additional anatomic and clinical variable that must be taken into consideration to ensure procedural safety and efficacy. We describe the Medtronic CoreValve percutaneous aortic valve implantation using the subclavian arterial approach in patients with a patent left internal thoracic artery and report our study's findings. The CoreValve percutaneous aortic valve is a self-expandable nitinol-based frame with a porcine pericardial valve. The subclavian access was created by a small infraclavicular surgical incision to expose the artery. Rapid ventricular pacing was used to reduce cardiac output to perform the balloon aortic valvuloplasty via a 12F sheath inserted into the subclavian artery. An 18F sheath was then inserted into the artery down into the ascending aorta and used for introduction of the delivery catheter and implantation of the percutaneous aortic valve. With the use of this method, 19 patients (76 ± 13 years) whose surgical risk was deemed excessive because of severe comorbidity and in whom transfemoral catheterization was considered unfeasible or at risk of severe complications have received implants. Subclavian artery or left internal thoracic artery injury did not occur in any patient. Two deaths occurred. One patient died of right coronary artery occlusion during the procedure, and one patient died 48 hours after the procedure as the result of a tamponade after the temporary pacemaker wire ablation. This initial experience suggests that subclavian transarterial aortic valve implantation in patients with a patent left internal thoracic artery to left anterior descending artery is feasible and safe with satisfactory short-term outcomes.

Internal thoracic artery injury after transvenous pacemaker implantation

Internal thoracic artery injury after transvenous pacemaker implantation

Atypical results of thoracic aortography performed to exclude aortic injury

This study was undertaken to determine the incidence and spectrum of “equivocal” findings on thoracic aortography performed: (a) to exclude traumatic aortic injury (TAI), and (b) to identify radiologic signs that might be useful in increasing diagnostic confidence. All cases of thoracic aortography performed during a 5-year period to evaluate possible major thoracic arterial injury were identified. Those with atypical or uncertain results were reviewed by the authors, and medical records were analyzed to determine initial diagnosis, management course, and clinical outcome.

The potential effects of radiographic criteria to exclude aortography in patients with blunt chest trauma: Results of a study of 32 patients with proved aortic or brachiocephalic arterial injury

The purpose of this study was to test the effectiveness, in patients with known aortic or brachiocephalic arterial injury, of five previously published radiographic criteria for excluding aortography in patients with blunt chest trauma. These criteria were (1) normal findings on erect chest radiograph; (2) normal aortic arch and left subclavian artery; (3) normal aortic arch, descending aorta, aortopulmonary window, tracheal position, and left paraspinal interface; (4) normal right paratracheal stripe and nasogastric tube position, and (5) normal aortic arch and tracheal and nasogastric tube position. One or more of these criteria were met in 6% to 25% of patient with major thoracic arterial injury, depending on the criteria used. Interestingly, two (6%) patients had radiographs that showed no specific signs of mediastinal hemorrhage, which indicates that the chest radiograph is limited in its sensitivity to detect major thoracic arterial injury. Because of these results, we do not believe that attempts to limit aortography in patients with supine film evidence of mediastinal abnormality, based on the absence of certain signs of mediastinal hemorrhage, are warranted. Furthermore, an abnormal radiograph cannot be relied on as the sole criterion for aortography if the goal of care is to detect as close to 100% of vascular injuries as possible.

Mediastinal hemorrhage: an evaluation of radiographic manifestations.

Eleven common radiographic signs of mediastinal hemorrhage were evaluated by two observers for the following three patient groups: normal subjects, patients with mediastinal hemorrhage and no arterial injury, and patients with major thoracic arterial injury. Supine chest radiographs were studied in all cases. Four major conclusions can be made based upon these findings. M/C ratio (mediastinal width to chest width), tracheal deviation, left hemothorax, paraspinal line widening, and aorto-pulmonary window opacification do not reliably separate these three groups of patients. The diagnosis of mediastinal hemorrhage may be made if the aortic contour is abnormal or if one of the following signs is positive: abnormal mediastinal width, apical cap, widening of the right paratracheal stripe, or deviation of the nasogastric tube. If either the right paratracheal stripe is widened or the nasogastric tube is deviated, the diagnosis of aortic rupture can be made with a 24% probability; if both signs are negative, there is a 98% probability that aortic rupture is absent. Due to interobserver variation, there is good agreement between observers for the following four signs only: transverse mediastinal width, tracheal deviation, nasogastric tube deviation, and right paratracheal stripe widening.