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Emergency Medicine Journal : EMJ Jul 2004Thoracic aortic rupture (TAR) is recognised as a cause of death in victims of blunt trauma. Immediate mortality is 85% but in the group who survive to reach hospital... (Review)
Review
Thoracic aortic rupture (TAR) is recognised as a cause of death in victims of blunt trauma. Immediate mortality is 85% but in the group who survive to reach hospital there is a reasonable chance of successful surgical repair. TAR can be remarkably occult and the emergency physician is paramount in making the initial diagnosis. If suggestive, but often subtle features are not recognised in the early phase they will go undetected until full rupture and death occurs. This article reviews the mechanism of injury and describes the signs and symptoms of TAR in the acute phase. Features suggestive of TAR on the initial primary survey chest radiograph are described. The use of this film as a screening tool, and of other imaging modalities, is discussed.
Topics: Aorta, Thoracic; Aortic Rupture; Aortography; Echocardiography, Transesophageal; Humans; Tomography, X-Ray Computed
PubMed: 15208221
DOI: No ID Found -
Journal of Vascular Surgery Oct 2022Emergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel...
Comparative early results of in situ fenestrated endovascular aortic repair and other emergent complex endovascular aortic repair techniques for ruptured suprarenal and thoracoabdominal aortic aneurysms at a regional aortic center.
INTRODUCTION
Emergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting, physician-modified endografts, double-barrel/reversed iliac branch device, and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAAs and TAAAs.
METHODS
A retrospective review of patients who underwent endovascular repair of ruptured SRAAAs and TAAAs from July 2014 to March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared with those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia.
RESULTS
Forty-two patients underwent endovascular repair for ruptured SRAAAs and TAAAs, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive before surgery, compared with 46% of the patients who underwent repair using non-ISF techniques (physician-modified endografts, parallel grafting, or double-barrel/reversed iliac branch device). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. Compared with the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P = .048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly used technique later in the study period.
CONCLUSIONS
Although emergent endovascular repair of ruptured SRAAAs/TAAAs remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a fivefold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up are needed to validate these initial results and assess durability.
Topics: Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Hypotension; Kidney Diseases; Postoperative Complications; Prosthesis Design; Risk Factors; Time Factors; Treatment Outcome
PubMed: 35697311
DOI: 10.1016/j.jvs.2022.04.036 -
Annals of Biomedical Engineering Jan 2016Dissection of an artery is characterised by the separation of the layers of the arterial wall causing blood to flow within the wall. The incidence rates of thoracic... (Review)
Review
Dissection of an artery is characterised by the separation of the layers of the arterial wall causing blood to flow within the wall. The incidence rates of thoracic aortic dissection (AoD) are increasing, despite falls in virtually all other manifestations of cardiovascular disease, including abdominal aortic aneurysm (AAA). Dissections involving the ascending aorta (Type A) are a medical emergency and require urgent surgical repair. However, dissections of the descending aorta (Type B) are less lethal and require different clinical management whereby the patient may not be offered surgery unless complicating factors are present. But how do we tell if a patient will develop a complication later on? Currently, there is no consensus and the evidence base is limited. There is an opportunity for computational biomechanics to help clinicians decide as to which cases to repair and which to manage with blood pressure control. In this review article, we look at AoD from both the clinical and biomechanical perspective and discuss some of the recent computational studies of both Type A and B AoD. We then focus more on Type B where the real opportunity for patient-specific modelling exists. Finally, we look ahead at some of the promising areas of research that may help clinicians improve the decision-making process surrounding Type B AoD.
Topics: Animals; Aortic Aneurysm, Abdominal; Aortic Rupture; Computer Simulation; Humans; Models, Cardiovascular
PubMed: 26101036
DOI: 10.1007/s10439-015-1366-8 -
Deutsches Arzteblatt International Oct 2012Ruptured abdominal aortic aneurysm (rAAA) remains a challenging problem: 2,410 cases were treated in Germany in 2010. Ruptured abdominal aortic aneurysm should be... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Ruptured abdominal aortic aneurysm (rAAA) remains a challenging problem: 2,410 cases were treated in Germany in 2010. Ruptured abdominal aortic aneurysm should be suspected in patients over age 50 who complain of pain in the abdomen or back and in whom examination reveals a pulsatile abdominal mass. The incidence of hospitalization for rAAA is 12 per 100,000 persons over age 65 per year (statistics for Germany, 2010), and rAAA carries an overall mortality of 80%.
METHODS
The current state of knowledge of rAAA was surveyed in a selective review of pertinent literature retrieved by an electronic search in the PubMed, Web of Science, and Cochrane Library databases with the keywords "abdominal aortic aneurysm," "ruptured," "open repair," and "endovascular." Publications in English or German up to and including March 2012 were considered, among them the Clinical Practice Guidelines of the European Society for Vascular Surgery (1).
RESULTS AND CONCLUSIONS
Recent reports show that the treatment of rAAA is still fraught with high mortality and high perioperative morbidity. Improvement is needed. It would be advisable for the care of rAAA to be centralized in specialized vascular centers implementing defined treatment pathways. Systematic screening, too, would be beneficial. An increasing number of reports suggest that endovascular treatment with stent prostheses improves outcomes; more definitive evidence on this matter will come from prospective, randomized trials that are now in progress.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Comorbidity; Germany; Humans; Postoperative Complications; Practice Patterns, Physicians'; Prevalence; Risk Factors; Survival Analysis; Survival Rate
PubMed: 23181137
DOI: 10.3238/arztebl.2012.0727 -
Journal of Vascular Surgery Jan 2022
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; COVID-19; Humans; SARS-CoV-2
PubMed: 34774979
DOI: 10.1016/j.jvs.2021.10.003 -
The Journal of Thoracic and... Feb 2021
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Aortic Rupture; Dissection; Humans
PubMed: 31859067
DOI: 10.1016/j.jtcvs.2019.11.031 -
European Journal of Vascular and... Mar 2015To compare biomechanical rupture risk parameters of asymptomatic, symptomatic and ruptured abdominal aortic aneurysms (AAA) using finite element analysis (FEA). (Comparative Study)
Comparative Study
OBJECTIVES
To compare biomechanical rupture risk parameters of asymptomatic, symptomatic and ruptured abdominal aortic aneurysms (AAA) using finite element analysis (FEA).
STUDY DESIGN
Retrospective biomechanical single center analysis of asymptomatic, symptomatic, and ruptured AAAs. Comparison of biomechanical parameters from FEA.
MATERIALS AND METHODS
From 2011 to 2013 computed tomography angiography (CTA) data from 30 asymptomatic, 15 symptomatic, and 15 ruptured AAAs were collected consecutively. FEA was performed according to the successive steps of AAA vessel reconstruction, segmentation and finite element computation. Biomechanical parameters Peak Wall Rupture Risk Index (PWRI), Peak Wall Stress (PWS), and Rupture Risk Equivalent Diameter (RRED) were compared among the three subgroups.
RESULTS
PWRI differentiated between asymptomatic and symptomatic AAAs (p < .0004) better than PWS (p < .1453). PWRI-dependent RRED was higher in the symptomatic subgroup compared with the asymptomatic subgroup (p < .0004). Maximum AAA external diameters were comparable between the two groups (p < .1355). Ruptured AAAs showed the highest values for external diameter, total intraluminal thrombus volume, PWS, RRED, and PWRI compared with asymptomatic and symptomatic AAAs. In contrast with symptomatic and ruptured AAAs, none of the asymptomatic patients had a PWRI value >1.0. This threshold value might identify patients at imminent risk of rupture.
CONCLUSIONS
From different FEA derived parameters, PWRI distinguishes most precisely between asymptomatic and symptomatic AAAs. If elevated, this value may represent a negative prognostic factor for asymptomatic AAAs.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Aortography; Asymptomatic Diseases; Biomechanical Phenomena; Finite Element Analysis; Germany; Hemodynamics; Humans; Male; Middle Aged; Models, Cardiovascular; Predictive Value of Tests; Prognosis; Regional Blood Flow; Retrospective Studies; Risk Assessment; Risk Factors; Stress, Mechanical; Tomography, X-Ray Computed
PubMed: 25542592
DOI: 10.1016/j.ejvs.2014.11.010 -
PloS One 2020We present a data-informed, highly personalized, probabilistic approach for the quantification of abdominal aortic aneurysm (AAA) rupture risk. Our novel framework...
We present a data-informed, highly personalized, probabilistic approach for the quantification of abdominal aortic aneurysm (AAA) rupture risk. Our novel framework builds upon a comprehensive database of tensile test results that were carried out on 305 AAA tissue samples from 139 patients, as well as corresponding non-invasively and clinically accessible patient-specific data. Based on this, a multivariate regression model is created to obtain a probabilistic description of personalized vessel wall properties associated with a prospective AAA patient. We formulate a probabilistic rupture risk index that consistently incorporates the available statistical information and generalizes existing approaches. For the efficient evaluation of this index, a flexible Kriging-based surrogate model with an active training process is proposed. In a case-control study, the methodology is applied on a total of 36 retrospective, diameter matched asymptomatic (group 1, n = 18) and known symptomatic/ruptured (group 2, n = 18) cohort of AAA patients. Finally, we show its efficacy to discriminate between the two groups and demonstrate competitive performance in comparison to existing deterministic and probabilistic biomechanical indices.
Topics: Aorta; Aortic Aneurysm, Abdominal; Aortic Rupture; Biomechanical Phenomena; Case-Control Studies; Female; Humans; Male; Models, Theoretical; Patient-Specific Modeling
PubMed: 33211767
DOI: 10.1371/journal.pone.0242097 -
European Journal of Vascular and... Nov 2021
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; COVID-19; Clinical Decision-Making; Elective Surgical Procedures; Health Services Needs and Demand; Humans; Needs Assessment; Patient Safety; Risk Assessment; Risk Factors; Vascular Surgical Procedures
PubMed: 34452839
DOI: 10.1016/j.ejvs.2021.06.033 -
Annals of Vascular Surgery May 2022The "crescent sign" is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been...
BACKGROUND
The "crescent sign" is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been associated with aneurysm instability or impending rupture, the literature is largely based on retrospective analyses of urgently repaired aneurysms. We strove to more rigorously assess the association between an isolated "crescent sign" and risk of impending aortic rupture.
METHODS
Patients were identified by querying a single health system PACS database for radiology reports noting a crescent sign. Adult patients with a CT demonstrating a descending thoracic, thoracoabdominal, or abdominal aortic aneurysm and "crescent sign" between 2004 and 2019 were included, with exclusion of those showing definitive signs of aortic rupture on imaging.
RESULTS
A total of 82 patients were identified. Aneurysm size was 7.1 ± 2.0 cm. Thirty patients had emergent or urgent repairs during their index admission (37%), 19 had elective repairs at a later date (23%), and 33 patients had no intervention due to either patient choice or prohibitive medical comorbidities (40%). Patients without intervention had a median follow up of 275 days before death or loss to follow up. In patients undergoing elective intervention, 6,968 patient-days elapsed between presentation and repair, with zero episodes of acute rupture (median 105 days). Patients undergoing elective repair had smaller aneurysms compared to those who underwent emergent/urgent repair (6.2 ± 1.3 vs. 7.7 ± 2.1 cm, P = 0.008). No surgical candidate with an aneurysm smaller than 8 cm ruptured. There were 31 patients with previous axial imaging within 2 years prior to presentation with a "crescent sign," with mean aneurysm growth rate of 0.85 ± 0.62 cm per 6 months [median 0.65, range 0-2.6]. Those with aneurysms sized below 5.5 cm displayed decreased aneurysm growth compared to patients with aneurysm's sized 5.5-6.5 cm or patients with aneurysms greater than 6.5 cm (0.12 vs. 0.64 vs. 1.16 cm per 6 months, P= 0.002).
CONCLUSIONS
The finding of an isolated radiographic "crescent sign" without other signs of definitive aortic rupture (i.e., hemothorax, aortic wall disruption, retroperitoneal bleeding) is not necessarily an indicator of impending aortic rupture, but may be found in the setting of rapid aneurysm growth. Many factors, including other associated radiographic findings, aneurysm size and growth rate, and patient symptomatology, should guide aneurysm management in these patients. We found that patients with minimal symptoms, aneurysm sizes below 6.5 cm, and no further imaging findings of aneurysm instability, such as periaortic fat stranding, can be successfully managed with elective intervention after optimization of comorbid factors with no evidence of adverse outcomes.
Topics: Adult; Aorta; Aortic Aneurysm, Abdominal; Aortic Rupture; Humans; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 34788704
DOI: 10.1016/j.avsg.2021.10.043