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European Journal of Trauma and... Jun 2022Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early...
PURPOSE
Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).
METHODS
Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.
RESULTS
Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).
CONCLUSION
This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.
Topics: Aorta; Endovascular Procedures; Humans; Quality of Life; Retrospective Studies; Thoracic Injuries; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 32632630
DOI: 10.1007/s00068-020-01432-y -
Revista Da Associacao Medica Brasileira... 2022We investigated the relationship between thoracic diameters and chest compression-related thoracoabdominal injury in patients with non-traumatic out-of-hospital cardiac...
OBJECTIVE
We investigated the relationship between thoracic diameters and chest compression-related thoracoabdominal injury in patients with non-traumatic out-of-hospital cardiac arrest who had a return of spontaneous circulation after cardiopulmonary resuscitation.
METHODS
A total of 63 consecutive adult non-traumatic out-of-hospital cardiac arrest patients were enrolled in this prospective study. Computed tomography was performed on each patient and the anteroposterior diameter, skin-to-skin anteroposterior diameter, and transverse diameter of the chest were measured. Patients were divided into two groups based on the presence or absence of cardiopulmonary resuscitation-related thoracoabdominal injury. Age, sex, and duration of cardiopulmonary resuscitation, anteroposterior diameter, skin-to-skin anteroposterior diameter, and transverse diameter were compared between the groups. The primary outcome was the relationship between thoracic diameters and cardiopulmonary resuscitation-induced thoracoabdominal injuries.
RESULTS
Thoracoabdominal injuries were detected in 46% (n=29) of the patients and consisted of rib fractures in 22 (34.9%) patients, pulmonary contusion in 7 (11.1%), and sternal fracture in 3 (4.8%) patients. There were no significant differences in cardiopulmonary resuscitation duration between patients with and without thoracoabdominal injuries (p=0.539). Similarly, there were no significant differences in anteroposterior diameter, skin-to-skin anteroposterior diameter, or transverse diameter between patient groups (p=0.978, p=0.730, and p=0.146, respectively) or between patients who died within the first 28 days and those who survived for longer than 28 days (p=0.488, p=0.878, and p=0.853, respectively).
CONCLUSION
The iatrogenic thoracoabdominal injuries caused by cardiopulmonary resuscitation performed according to the cardiopulmonary resuscitation guidelines were independent of thoracic diameters. Therefore, the cardiac compression depth of 5-6 cm recommended by the current cardiopulmonary resuscitation guidelines is reliable for patients with different thoracic diameters.
Topics: Adult; Humans; Out-of-Hospital Cardiac Arrest; Prospective Studies; Cardiopulmonary Resuscitation; Thoracic Injuries; Fractures, Bone
PubMed: 36417655
DOI: 10.1590/1806-9282.20220822 -
Journal of Vascular Surgery Jul 2022Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend...
OBJECTIVE
Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management.
METHODS
We performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability.
RESULTS
A total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography.
CONCLUSIONS
Nonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.
Topics: Aneurysm, False; Aorta, Thoracic; Endovascular Procedures; Hematoma; Humans; Retrospective Studies; Thoracic Injuries; Time Factors; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 35314302
DOI: 10.1016/j.jvs.2022.03.012 -
International Orthopaedics Dec 2023The purpose of this study is to present a classification of thoracic spine fractures based on anatomical and biomechanical characteristics. (Review)
Review
PURPOSE
The purpose of this study is to present a classification of thoracic spine fractures based on anatomical and biomechanical characteristics.
METHODS
This is a narrative review of the literature.
RESULTS
The classification is based on the relationship between movement and common forces acting on the spine. A mechanistic concept is incorporated into the classification, which considers both movements and the application of forces, leading to pathomorphological characteristics. A hierarchical ranking determines the severity of fractures within the thoracic spine, and treatment recommendations are presented in each category. The fourth column of the spine is incorporated into the classification through direct and indirect mechanisms.
CONCLUSIONS
The proposed classification accommodates several advantages, such as simplicity and practicality, that make this classification helpful in daily practice. The dynamic relationship between movement and force provides a better understanding of the fracture mechanism. Finally, incorporating the fourth column will strengthen the indication for surgical management. To the best of our knowledge, this classification is the first classification developed uniquely for the thoracic spine fractures and will help to address a critical gap in the literature.
Topics: Humans; Spinal Fractures; Sternum; Thoracic Vertebrae; Fractures, Bone; Thoracic Injuries
PubMed: 36943457
DOI: 10.1007/s00264-023-05778-x -
Cell Biochemistry and Biophysics Sep 2021Radiation-induced lung injury (RILI) is a potential complication of thoracic radiotherapy that can result in pneumonitis or pulmonary fibrosis and is associated with... (Review)
Review
Radiation-induced lung injury (RILI) is a potential complication of thoracic radiotherapy that can result in pneumonitis or pulmonary fibrosis and is associated with significant morbidity and mortality. The pathobiology of RILI is complex and includes the generation of free radicals and DNA damage that precipitate oxidative stress, endothelial cell (EC), and epithelial cell injury and inflammation. While the cellular events involved continue to be elucidated and characterized, targeted and effective therapies for RILI remain elusive. Sphingolipids are known to mediate EC function including many of the cell signaling events associated with the elaboration of RILI. Sphingosine-1-phosphate (S1P) and S1P analogs enhance EC barrier function in vitro and have demonstrated significant protective effects in vivo in a variety of acute lung injury models including RILI. Similarly, statin drugs that have pleiotropic effects that include upregulation of EC S1P receptor 1 (S1PR1) have been found to be strongly protective in a small animal RILI model. Thus, targeting of EC sphingosine signaling, either directly or indirectly, to augment EC function and thereby attenuate EC permeability and inflammatory responses, represents a novel and promising therapeutic strategy for the prevention or treatment of RILI.
Topics: Lung Injury
PubMed: 34370281
DOI: 10.1007/s12013-021-01022-8 -
European Journal of Vascular and... 2022Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however,... (Review)
Review
OBJECTIVE
Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however, it has also been demonstrated to alter cardiovascular haemodynamics. The aim of this systematic review was to describe the cardiovascular modifications after thoracic endovascular aortic repair (TEVAR) for BTAI.
DATA SOURCES
PubMed (MEDLINE), Scopus, and Web of Science were systematically searched for eligible studies reporting on modifications in aortic stiffness, blood pressure, cardiac mass, and aortic size.
REVIEW METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies.
RESULTS
A total of 12 studies reporting on 265 patients were included. Severe heterogeneity existed among the included studies with regard to demographics, BTAI grade, endograft specifications, reported outcomes, and the method of evaluation. Regarding aortic stiffness, two studies found a significant increase in pulse wave velocity (PWV) in patients after TEVAR compared with a control group, while one did not find a significant increase in PWV and augmentation index after > 3 years of follow up. Five studies reported an increase in the incidence of post-TEVAR hypertension up to 55% (range 34.8% - 55.0%) vs. baseline. One study found a statistically significant increase in left ventricular mass and left ventricular mass index during follow up. Nine studies report data regarding aortic dilatation or remodelling after TEVAR. One found a 2.4 fold faster growth rate in ascending aortic diameter vs. controls, while other studies described significant changes in aortic size at different locations along the aorta and endograft after TEVAR.
CONCLUSION
This systematic review highlights adverse cardiac and aortic modifications after TEVAR for BTAI. The results stress the need for lifelong surveillance in these patients and the necessity of developing a more compliant endograft to prevent cardiovascular complications in the long term.
Topics: Humans; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Pulse Wave Analysis; Vascular System Injuries; Retrospective Studies; Thoracic Injuries; Wounds, Nonpenetrating; Aorta, Thoracic; Treatment Outcome
PubMed: 35537638
DOI: 10.1016/j.ejvs.2022.05.004 -
Colombia Medica (Cali, Colombia) Apr 2021Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care... (Review)
Review
Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.
Topics: Algorithms; Colombia; Drainage; Heart Injuries; Hemorrhage; Hemostatic Techniques; Humans; Medical Illustration; Pericardial Window Techniques; Postoperative Complications; Therapeutic Irrigation; Ultrasonography; Wounds, Penetrating
PubMed: 34188321
DOI: 10.25100/cm.v52i2.4519 -
European Journal of Trauma and... Aug 2021Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms...
PURPOSE
Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma.
METHODS
This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest.
RESULTS
Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy.
CONCLUSIONS
The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.
Topics: Flail Chest; Humans; Retrospective Studies; Rib Fractures; Thoracic Injuries; Thoracic Wall; Wounds, Nonpenetrating
PubMed: 30953111
DOI: 10.1007/s00068-019-01119-z -
European Review For Medical and... Jun 2021We aimed at investigating the effects of clinical data, urgent thoracotomy (UT) indications and results on prognosis and mortality in traumatic and non-traumatic...
OBJECTIVE
We aimed at investigating the effects of clinical data, urgent thoracotomy (UT) indications and results on prognosis and mortality in traumatic and non-traumatic patients who were and underwent UT in the operating room.
PATIENTS AND METHODS
Patients (17-90 years old) who were admitted to the Emergency Department of Afyonkarahisar State Hospital between 01.01.2012 and 31.06.2020 with traumatic and non-traumatic reasons requiring UT were retrospectively conducted from the archive. The patients' age, gender, complaints during admission, trauma classification, reports of thorax images, injury sites accompanying trauma, hospitalization and mortality rates were examined. IBM SPSS 22.0 program was used to compare all the data obtained.
RESULTS
During the 90-month study period, a total of 40 patients who were admitted for traumatic and non-traumatic reasons were applied UT. The mean age of all patients (77.5% male, 22.5% female) was 33.35±14.1 years. There were 55% penetrating injuries, 32.5% blunt injuries and 12.5% non-traumatic causes. Indications for UT in the study were; massive hemothorax (25%), diaphragmatic rupture (22.5 %), hypovolemic shock (25%), heart or great vessel injuries (15%), massive air leak despite thoracostomy (10%), rupture of the pulmonary hydatid cyst into the bronchus and accompanying hemoptysis (2.5%). The time to surgical procedure in patients who underwent thoracotomy was shorter in patients with death. Mean time to thoracotomy was 4.5±6.5 hours. Mortality of UT was 20% with survival of 80%.
CONCLUSIONS
In the context of indications, urgent thoracotomy reduces mortality. The cooperation between the emergency physician and the thoracic surgeon is important during the decision phase.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Emergency Service, Hospital; Female; Hospitalization; Humans; Male; Middle Aged; Prognosis; Thoracic Injuries; Thoracotomy; Wounds, Nonpenetrating; Wounds, Penetrating; Young Adult
PubMed: 34227069
DOI: 10.26355/eurrev_202106_26143 -
Fa Yi Xue Za Zhi Aug 2022To analyze the characteristics of thoracic aorta injury in road traffic accidents, to provide data reference for forensic identification.
OBJECTIVES
To analyze the characteristics of thoracic aorta injury in road traffic accidents, to provide data reference for forensic identification.
METHODS
The data of 27 traffic accident death cases with thoracic aorta injury were analyzed according to relevant parameters including sex, age, mode of transportation, and thoracic aorta injury.
RESULTS
Aortic injury in traffic accidents was significantly more in males than females, and 74.1% cases were in the age range of 31-70 years. The most common mode of transportation was the motorcycle, followed by electric bike, most of which crashed with trucks. Most cases were accompanied by rib fractures and lung injuries. Thoracic aorta injury was the most common in ascending aorta, followed by aortic arch and thoracic aorta. Ascending aorta injury was most likely to occur in the range of 0-<1.6 cm from the aortic valve, while it was rare over 2.6 cm. Taking the aortic valve as the reference, the most common locations of injury were the anterior semilunar valve, followed by the right posterior semilunar valve and the left posterior semilunar valve. Thoracic aortic rupture occurred in 63.0% cases, and intima and media lacerations only occurred in 37.0% cases. A few deceased had aortic diseases.
CONCLUSIONS
The proximal part of the ascending aorta is prone to be injured because of the large external force of traffic accidents. The medical examiner should carefully examine the aortic injury in traffic accident deaths, and evaluate the relationship between the injury and the disease according to the condition and degree of aortic injury.
Topics: Male; Female; Humans; Adult; Middle Aged; Aged; Aorta, Thoracic; Accidents, Traffic; Thoracic Injuries; Aortic Rupture; Rib Fractures
PubMed: 36426692
DOI: 10.12116/j.issn.1004-5619.2020.410502