Traumatic Thoracic Aortic Injury Research Articles

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 We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI.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.

Outcomes after thoracic endovascular aortic repair in patients with traumatic thoracic aortic injuries—a single-centre retrospective review

Blunt and penetrating traumatic thoracic aortic injuries constitute surgical emergencies that are attended with high mortality rates. Most patients do not survive long enough, post injury, to reach a hospital. On-site mortality rates may approach approximately 85%. Two main treatment options for blunt thoracic aortic injuries are open surgery and thoracic endovascular repair. Penetrating thoracic aortic injuries have a higher mortality than blunt trauma, with patients often only reaching the hospital in extremis. Thoracic endovascular repair is currently rapidly evolving as the standard of care for thoracic aortic injuries at many centres. This is a ten-years retrospective study during which data from December 2006 to December 2016 was collected, yielding 34 patients (30 blunt trauma, 4 penetrating trauma). These injuries were treated with thoracic aortic stent grafts at the Groote Schuur Hospital Vascular Unit, Cape Town. We assessed the technical and clinical outcomes. The 30-day mortality rate was 5.8%, corresponding to 2 deaths both associated with the index trauma-related fatal strokes. The overall mortality rate was 11.8% (4/34): three deaths were due to major strokes and one death was related to pulmonary complications. Thoracic endovascular repair after traumatic aortic injury is associated with significantly lower procedural and post-operative mortality. The 30-day and overall mortality after thoracic endovascular repair in our unit is comparable to international standards. Even though there is a paucity of literature on penetrating traumatic aortic injury, thoracic endovascular repair has low peri-procedural adverse events and is safe in selected patients.

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.

Association between Timing of Traumatic Thoracic Aortic Injury Repair and Outcome: A National Trauma Databank Study

Association between Timing of Traumatic Thoracic Aortic Injury Repair and Outcome: A National Trauma Databank Study

Cross-sectional imaging of thoracic traumatic aortic injury.

Aortic injury remains a major contributor to morbidity and mortality from acute thoracic trauma. While such injuries were once nearly uniformly fatal, the advent of cross-sectional imaging in recent years has facilitated rapid diagnosis and triage, greatly improving outcomes. In fact, cross-sectional imaging is now the diagnostic test of choice for traumatic aortic injury (TAI), specifically computed tomography angiography (CTA) in the acute setting and CTA or magnetic resonance angiography (MRA) in follow-up. In this review, we present an up-to-date discussion of acute traumatic thoracic aortic injury with a focus on optimal and emerging CT/MR techniques, imaging findings of TAI, and potential pitfalls.

Effect of emergency thoracic endovascular aortic repair in patients with acute traumatic thoracic aortic injury

Objective: To investigate the effect of emergency thoracic endovascular aortic repair (TEVAR) in patients with acute traumatic thoracic aortic injury. Method: From January 2014 to December 2016, a total of 35 patients with acute traumatic thoracic aortic injuries were treated with emergency TEVAR in our hospital, their clinical data were analyzed retrospectively in this study. Results: The patients were 42 (34, 55) years old,and there were 31 males.All cases were diagnosed by emergency aorta computed tomography angiography (CTA),and 5 cases were diagnosed as aortic transaction, 13 cases were diagnosed as aortic pseudoaneurysm, 7 cases were diagnosed as aortic dissection, and 10 cases were diagnosed as aortic intramural hematoma combined hemothorax.The concomitant injuries included cerebral contusion (3 cases, 8.6%), pulmonary contusion with rib fracture (31 cases, 88.5%), long bone fracture (7 cases, 22.5%), contusion of viscera or internal organs (3 cases, 8.6%).Emergency TEVAR were performed with vascular suture system preset under local anesthesia after diagnosis,and combined injury was treated in related departments.CTA was repeated after 1, 3 and 6 months and yearly thereafter. One patient died before transferring to catheter room,and 34 (97.1%) patients underwent TEVAR procedure successfully.Time from door to operating room was (88.6±26.6) minutes,and the procedure time was (52.0±9.4) minutes. A total of 69 Perclose Proglide vascular suture system were used,and 2 cases underwent surgical suture because of hematoma and pseudoaneurysm formation in femoral arteries.The involved length of thoracic aorta was (44.5±7.4)mm. A total of 46 stent-grafts were implanted, the length of stent-graft was (164.3±15.2)mm,and the proximal oversize rate was (22.3±8.6)%. The follow-up time was 24 (12,24) months, and there were no procedure related complication such as endoleak and paraplegia. Complete aortic remodeling was observed in 14 cases. Fully thrombolization at stent segments were observed in 7 cases. Fully thrombalization of pseudoaneurysms were observed in 13 cases. One patient complained mild left upper limb weakness due to left subclavian artery occlusion. Conclusion: Emergency TEVAR is safe and effective procedure for the treatment of patients with acute traumatic thoracic aortic injury.

Risk Factors for Mortality After Endovascular Repair for Traumatic Thoracic Aortic Injury

Risk Factors for Mortality After Endovascular Repair for Traumatic Thoracic Aortic Injury

Improving Surveillance of Traumatic Thoracic Aortic Injuries Repaired with Thoracic Endovascular Graft Placement

The optimal follow-up protocol for patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury remains unclear. The objective of this study was to assess follow-up patterns in such patients and present an approach to improve long-term follow-up in this cohort. The University of Louisville Trauma Registry was queried for patients who underwent TEVAR for traumatic thoracic aortic injuries between 2006 and 2016. Demographic, injury-specific, perioperative, and outcome measures were recorded for each patient. Follow-up evaluation and duration of follow-up were captured. Follow-up imaging was reviewed for any evidence of vascular complications. A total of 56 patients underwent TEVAR for traumatic thoracic aortic injury. Median age was 48 (range 18-86). Injury mechanism was largely blunt trauma (55 (98%)). Median injury severity score was 34 (range 17-43). Median length of stay was 12.5 days (range 1-40 days), and 51 patients (91%) survived to discharge. Of these, 30 (54%) made at least one follow-up appointment, and 21 of those 30 (70%) received a follow-up CT scan. Median time to last follow-up was one month (range 0-48 months), with 12 patients (21%) having follow-up beyond two months. No patients demonstrated any evidence of vascular complications on imaging at last follow-up. Despite the increased use of TEVAR to treat traumatic aortic injuries, limited follow-up data exist to predict the long-term outcomes of such interventions. Development of statewide or regional databases may help better track outcomes and identify late complications.

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 thoracic aortic injury

Abstract Traumatic thoracic aortic injuries are rare in the pediatric population. Most patients sustaining this injury do not survive and succumb at the scene. Associated injuries can complicate the management of the aortic injury. Aortic injuries have traditionally been treated by open repair. In the adult population, endovascular stenting has become the management of choice. The pediatric literature has isolated reports of the use of endovascular stenting in the repair of aortic injuries. We report an 11 year old female with multiple injuries and a grade III thoracic rupture with a pseudoaneurysm successfully managed with endovascular stenting.

Open versus endovascular repair for the patients with acute traumatic injury of thoracic aorta

Open versus endovascular repair for the patients with acute traumatic injury of thoracic aorta

胸部大動脈損傷と横隔膜損傷を合併した鈍的外傷の1例

鈍的外傷に大動脈損傷を伴う場合，病院到着前の死亡例もあり救命困難である．胸部大動脈ステントグラフト内挿術（thoracic endovascular aortic repair:以下TEVAR）を併用することで低侵襲，短時間で大動脈の治療を行うことができ，救命に至った症例を経験した．症例は32歳，男性．大型バイクの事故で受傷した．来院時ショック状態であり，胸部単純X線・胸腹部造影CT検査で外傷性横隔膜ヘルニアと胸部大動脈損傷の診断となった．全身麻酔下でTEVARを施行後，開腹手術で横隔膜を修復した．術後23日目に自宅退院となった．大動脈損傷を伴う多発外傷では，複数の病態へ治療の優先順位が重要となり，短時間で治療が行えるTEVARの併用は有効である可能性が示唆された．

Endograft Coverage of the Left Subclavian Artery During Repair of Traumatic Thoracic Aortic Injury May Be Associated With Significant Long-Term Morbidity

Coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR) has reportedly minimal long-term sequelae. As it is being used frequently in traumatic aortic transection, we hypothesized that trauma patients with LSCA coverage may often require secondary interventions because of ischemic complications. We conducted a single-institution, retrospective chart review of 82 patients who underwent TEVAR for blunt aortic transection (2004-2014). Patient demographics, comorbidities, concomitant injuries, details of the intervention, and thoracic aortic injury grade were collected. The outcomes included were immediate and long-term mortality rates, stroke, endoleak, device migration, lesion regression, open conversion, and reintervention rates secondary to morbidity associated with LSCA coverage. Statistical analysis included χ2 test, Fisher exact test, t-test, and Kaplan-Meier analysis. Eighty-two patients were treated with TEVAR with a technical success rate of 100% and mean follow-up of 2.3 ± 2.4 years. Fifty-eight patients had TEVAR without LSCA coverage, whereas 23 patients (28.0%) required either partial or complete coverage. The overall 30-day mortality rate was 7.3% (n = 6), mostly due to associated injuries. Mortality was similar between those with and without LSCA coverage (6.9% vs 8.7%; P = 1.0). Patients with LSCA coverage had significantly more hemodynamic instability on presentation than those who did not require LSCA coverage (43% vs 19%; P = .023). Adverse events and reinterventions associated with LSCA included one patient who died of concomitant trauma and one who died of an immediate, massive posterior stroke resultant from LSCA coverage. One patient was immediately revascularized because of previous left internal mammary artery-left anterior descending artery bypass, and one was revascularized because of immediate arm ischemia. Of the remaining 18 who were discharged without immediate revascularization, 5 required delayed revascularization for exertional arm pain or ischemia (Table). One-year survival rates were similar between groups (90.9% vs 91.3%; P = .976). In this study, the LSCA required coverage in approximately a quarter of patients during TEVAR for traumatic aortic injury to achieve an adequate proximal seal zone. This was associated with a significant incidence of late arm symptoms requiring revascularization, suggesting that it is not as benign a procedure as initially thought.TableMorbidity related to left subclavian artery (LSCA) coverage during thoracic endovascular aortic repair (TEVAR)Patient No.Age, yearsTime to intervention, daysInterventionMorbidity1690NoneDeath due to posterior stroke2790Left carotid-subclavian bypassProphylactic revascularization for prior LIMA-LAD3710Left subclavian stentImmediate arm ischemia441865Graft explantation and open bypassArm claudication522693Left subclavian transpositionSubclavian steal syndrome630164Left subclavian transpositionSubclavian steal syndrome718835Left carotid-subclavian bypassSubclavian steal syndrome837672Left subclavian stentArm claudicationLIMA-LAD, Left internal mammary artery-left anterior descending artery. Open table in a new tab

Extension-Distraction Injury of the Thoracolumbar Spine With Associated Traumatic Thoracic Aortic Injury: A Case Report

Extension-Distraction Injury of the Thoracolumbar Spine With Associated Traumatic Thoracic Aortic Injury: A Case Report

Toward Reduction of Post–Hospital Admission Death Rate Caused by Acute Traumatic Aortic Tear

BackgroundTerminology and classifications are the vehicles by which pathologic conditions are identified and understood. It is critically important for the patient admitted with suspected blunt thoracic aortic injury that admitting physicians have a thorough knowledge of acute traumatic aortic tear and its natural history. ObjectivesThe objectives of this review were as follows: (1) to introduce a pathology-based terminology and classification of acute traumatic aortic injuries that unambiguously defines each, and (2) to emphasize the clinical relevance of acute traumatic tear to post–hospital admission deaths in blunt thoracoabdominally injured patients. MethodsThis is a literature review of 32 refereed articles pertaining to acute traumatic thoracic aortic injury published from 1957 to the present. ResultsThe terminology used to describe aortic injury is inconsistent. Several terms are often loosely interchanged: tear, laceration, transection, and rupture. Furthermore, classifications of aortic injuries have been proposed based on microscopic or gross pathologic or computed tomography scan results. While microscopically-based classifications have little or no clinical application, a classification based on gross pathology provides information useful for aortic injury prognosis and management. ConclusionReduction of post-hospital death caused by acute aortic tear requires knowledge and understanding of the pathology of acute traumatic aortic tear and its natural history. Such understanding of pathology of acute traumatic aortic tear and its natural history is enhanced by terminology that defines the aortic injury. Therefore, we present our proposed terminology and classification of acute traumatic injuries.

Late Radiological and Clinical Outcomes of Traumatic Thoracic Aortic Injury Managed with Thoracic Endovascular Aortic Repair

Patients treated with thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury (TTAI) are often young and data on long-term durability of this treatment is not widely documented. The aims of this study were to report the New Zealand (NZ) national experience of TEVAR and to assess the durability of late outcomes and radiological follow-up of patients treated for TTAI. Consecutive patients treated with TEVAR during a 12-year period from all tertiary centers in NZ were included. Early (30-day), late survival and radiological imaging data were recorded to document late graft-related complications and re-interventions. 88 patients with a median (range) age of 35 (15-87) year and 63 (71.6%) males were included. Eleven patients (12.5%) died within 30days, of which three were aortic related deaths. The median (range) follow-up was 76.3 (0.3-164.6) months. Six (7.8%) patients died during the follow-up period due to non-aortic-related causes. Nine (11.5%) patients were lost to follow-up of which three emigrated overseas. Of those on surveillance, two patients required TEVAR re-intervention to previously treated aortic segments; one for a type 1b endoleak and the other for a symptomatic pseudo-coarctation. Both were treated successfully with a TEVAR. This multicenter study suggests that TEVAR is a durable option for treatment of traumatic thoracic aortic injury. Although, stent graft complications were uncommon, but when it occurred, it leads to re-intervention. Further radiological follow-up is required particularly in young patient to document late aortic/stent complications.