|Year : 2022 | Volume
| Issue : 2 | Page : 39-43
Traumatic blunt aortic injury: experience in one hospital
Che-Hui Yeh1, Jiun-Yi Li2
1 Division of General Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
2 Division of Cardiovascular Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
|Date of Submission||15-Nov-2021|
|Date of Decision||07-Mar-2022|
|Date of Acceptance||29-Mar-2022|
|Date of Web Publication||25-Apr-2022|
No. 92, Sec. 2, Zhongshan N. Road, Taipei City 10449
Source of Support: None, Conflict of Interest: None
Background: Traumatic blunt aortic injury (TBAI) is a rare event with an incidence rate of approximately 2.6 patients per year at a medical center. However, high rates of early mortality render it the second leading cause of mortality among traumatic injuries. The optimal management and long-term outcomes after intervention therapy remain unclear. We reviewed TBAI cases in our hospital and discussed the surgical strategy.
Materials and Methods: We retrospectively analyzed ten patients diagnosed with TBAI between 2006 and 2019 in our Health insurance database. We used the grading system of the Society of Vascular Surgery. Patients who were classified as Grade 1 or 2 injuries received nonoperative treatment. Patients who were classified as Grade 3 or 4 injuries underwent surgical intervention. Follow-up computed tomography angiography was arranged within 1 year of discharge.
Results: Two and seven patients presented with Grade 2 and 3 aortic injuries, respectively. One patient incidentally found chronic Type B aortic dissection after trauma. For one early case, open aortic replacement was performed. Four (including one brain dead) patients received nonoperative treatment. Five patients underwent percutaneous thoracic endovascular aortic repair. Nine patients survived after treatment. Three of the five patients who underwent endovascular repair developed postoperative complications, including endoleak and paraplegia. Two patients who underwent nonoperative treatment showed complete resolution within 2 months.
Conclusion: In selected cases with Grade 2 injury, nonoperative treatment may be appropriate and complete resolution of intramural hematoma may occur.
Keywords: Endovascular repair, management, traumatic aortic blunt injury
|How to cite this article:|
Yeh CH, Li JY. Traumatic blunt aortic injury: experience in one hospital. Formos J Surg 2022;55:39-43
| Introduction|| |
Traumatic blunt aortic injury (TBAI) is a rare event with an incidence rate of approximately 2.6 patients per year at medical centers. It is the second leading cause of mortality among trauma types after brain injury. Over the past few decades, improved imaging modalities, surgical techniques, and therapeutic strategies have significantly decreased the mortality rate. However, there remains no consensus regarding the optimal timing for intervention. This study aims to review TBAI cases at our hospital and discusses surgical strategies.
| Materials and Methods|| |
This was a retrospective, single-centered case series. We searched the diagnostic code for aortic injury in the hospital's health insurance database from January 2006 to December 2019. We used both International Statistical Classification of Diseases and Related Health Problems (ICD)-9 and ICD-10 diagnostic codes for injury of the thoracic aorta (9010, S250) and abdominal aorta (9020, S350). Initially, we included 20 cases, with their medical records and images being carefully reviewed by two researchers. TBAI was defined as acute presentation after blunt trauma with positive findings on computed tomography angiography (CTA) in the aorta. We excluded cases without imaging examination for the confirmation of the diagnosis, cases with unclear records, or cases in which the final diagnosis at discharge was not TBAI.
We used the grading system of the Society of Vascular Surgery (SVS) for TBAI classification: Grade 1 – intimal tear, Grade 2 – intramural hematoma or large intimal flap, Grade 3 – pseudoaneurysm, and Grade 4 – free rupture. Patients who were classified as having Grade 1 or 2 injury underwent nonoperative treatment, with the blood pressure being controlled to <120 mmHg using a beta-blocker. Patients who were classified as having Grade 3 or 4 injury underwent percutaneous thoracic endovascular aortic repair (pTEVAR) or open aortic replacement as the definitive treatment. The timing for intervention was dependent on the hemodynamic status, and on other related injuries. In cases where hemodynamic status was stable, early intervention was planned. Patients with unstable hemodynamic status related to other trauma types underwent delayed aortic interventions after stabilization. In case of a poor condition directly related to TBAI, an emergency intervention was planned.
We collected data regarding demographics, related trauma and management, time to intervention, intraoperative blood loss, length of intensive care unit (ICU) stay, length of hospital stay, and postoperative complications. Follow-up CTA was performed within 1 year of discharge.
| Results|| |
Ten patients were diagnosed with TBAI from January 2006 to December 2019 at our hospital. The median patient age was 41-year-old. Nine patients had TBAI caused by traffic accident, while one patient fell from height. Male predominance (9/10) was noted in the cohort. Nearly, all patients had accompanying trauma types other than aortic injury (9/10). The median injury severity score was 25.5. The most common comorbid injuries were limb fracture or dislocation (9/10), rib fracture or hemopneumothorax (6/10), and intracranial hemorrhage (4/10). There were two and seven patients with Grade 2 and 3 aortic injury, respectively. One patient was incidentally found to have chronic Type B aortic dissection after trauma.
In one early case, the patient was diagnosed with Grade 3 aortic injury and right lower limb fracture. He underwent open aortic replacement on day 14 after admission, in 2006. A left thoracotomy was performed. We established cardiopulmonary bypass after left femoral artery and vein cannulation. The aortic pseudoaneurysm was resolved using a graft under deep hypothermic circulatory arrest. The intraoperative blood loss was 1500 cc. We performed successful extubation on postoperative day 1, and he was transferred to an ordinary ward on postoperative day 3. Further operation for the orthopedic injury was performed. The ICU and hospital stays were 15 and 31 days, respectively. He was lost to follow-up after 3 months.
Since 2011, five patients had undergone pTEVAR for Grade 3 aortic injury. The median time to intervention was 18 h. One patient had an epidural hemorrhage, and emergent craniectomy was planned before aortic repair due to consciousness change and asymmetric pupil size. The patient underwent pTEVAR on the 3rd day. The remaining four patients underwent early repair after stabilization of hemodynamic status, with approach through bilateral common femoral artery. After systemic heparinization, aortography was performed to localize the lesion and measure the thoracic aorta diameter. The stent grafts were oversized by 10%–20%. Stent grafts were deployed 1–2 cm proximal to the aorta and distal to the disruption site. Postprocedural angiography was performed to ensure adequate sealing. Two patients underwent chimney stent grafting through the left brachial artery. One patient underwent subclavian-to-subclavian artery bypass, with subsequent embolization of the root of the left subclavian artery. The median intraoperative blood loss was 50 cc (10–100 cc). The patient who underwent craniectomy was weaned from the ventilator on postoperative day 14, with a further 5 days in the ICU, and a total hospital stay of 47 days. In the remaining patients, the median duration of ventilator use, ICU stay, and hospital stay were 0 (0–6 days), 7 (6–11 days), and 24.5 (18–31 days) days, respectively.
Three patients who underwent pTEVAR developed postoperative complications. Postoperative angiography revealed Type 1a endoleak in two patients. No further interventions were performed. One patient was lost to follow-up. The other patients underwent CTA after discharge, which revealed a spontaneous improvement of the endoleak. Another patient presented with paraplegia after pTEVAR. His muscle power in the lower limbs normalized after spinal drainage. Follow-up CTA examination revealed residual dissection in the abdominal aorta.
Three patients received nonoperative treatment: One patient was diagnosed with chronic Type B aortic dissection not directly related to the trauma, and the other two patients were diagnosed with Grade 2 aortic injury. Blood pressure was controlled using a beta-blocker under intensive hemodynamic monitoring. The median ICU and hospital stays were 10 and 19 days, respectively. No complications were observed. Follow-up CTA revealed complete resolution within 2 months at the site of the Grade 2 aortic injury [Figure 1] and [Figure 2]. However, persistent dissection from the distal arch to the lower thoracic aorta was still observed in the patient with chronic Type B aortic dissection.
|Figure 1: A 73-year-old man fell from the fifth floor. First computed tomography angiography (left) in the emergency room showed Grade 2 traumatic blunt aortic injury. He received nonoperative treatment with beta-blocker. Follow-up computed tomography angiography (right) was planned one month after discharge and showed complete resolution of intramural hematoma. CTA: Computed tomography angiography; TBAI: Traumatic blunt aortic injury|
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|Figure 2: A 77-year-old female motorcycle rider collided with a car. First computed tomography angiography (left) in the emergency room showed Grade 2 traumatic blunt aortic injury. She received nonoperative treatment with beta-blocker. Follow-up computed tomography angiography (right) within 1 month after discharge showed complete resolution of intramural hematoma. CTA: computed tomography angiography; TBAI: traumatic blunt aortic injury|
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One patient who did not undergo aortic intervention due to brain injury, showed Grade 3 aortic injury. Although emergent extraventricular drainage was performed within a few hours, he remained in a coma. His family agreed to organ donation after brainstem death, with the organs being donated on the 3rd day after admission.
All demographics, interventions, postoperative complications, and length of ICU and hospital stays are summarized in [Table 1].
|Table 1: Demographics and outcomes of traumatic blunt aortic injury in a hospital between 2006 and 2019|
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| Discussion|| |
TBAI accounts for 2% of cases of blunt thoracic injury. Car accidents account for 70% of TBAI cases. The most common injury site is the distal part of the aortic isthmus. It may be caused by abrupt thorax deceleration in a high-speed vehicular accident. Other possible mechanisms include aortic torsion, sudden increase in intra-abdominal pressure, and aortic entrapment between the anterior chest wall and vertebral column. Patients usually present with multiple organ trauma, which may mask the signs and symptoms of aortic injury, including interscapular pain, upper trunk hypertension, shock, or sudden death. A previous study showed that 80% of patients died before arriving at the hospital. Among the patients who survived and reached the emergency room, 50% died within 24 h. The overall mortality rate for patients who arrive at the hospital alive is 32%. With the evolution of interventional therapy, it seems that endovascular therapy could reduce perioperative deaths, shorten hospital stays, and provide appropriate alternative treatments., However, the optimal management for TBAI is still controversial.
CTA advancement has allowed the detection of more cases of undiagnosed minimal aortic injury (MAI) in the emergency room. These patients may only present with positive imaging findings without symptoms or signs of aortic injury. However, there remains no standard definition of aortic abnormality that characterizes MAI or consensus regarding the management of these injuries. The use of different MAI definitions may affect management decisions.
The SVS recommends nonoperative therapy for Grade 1 injury, while operation is recommended for Grade 2, 3, and 4 injuries. However, the evidence level suggested by the SVS is only Grade 2C. Recent studies revealed that nonoperative therapy was feasible for low grade injury., In our series, two patients diagnosed with Grade 2 injury received nonoperative therapy. Follow-up CTA examinations were planned within 1 month of discharge and revealed complete resolution of intramural hematoma. Heneghan et al. reported that among 47 patients with Grade 1 or 2 aortic injury, 96% were nonoperatively managed without TBAI-related deaths, and 80% showed no progression on follow-up imaging. In our experience, patients diagnosed with Grade 2 aortic injury who have stable hemodynamic status may be successfully managed using nonoperative therapy.
Surgical management is recommended for patients diagnosed with Grade 3 or 4 aortic injury. The timing of the intervention is an important but still unresolved issue. The guidelines of the Eastern Association for the Surgery of Trauma (EAST) published in 2015 suggest that in hemodynamically stable patients, definitive TBAI management should be delayed until other acute life-threatening injuries are adequately managed and the patients are appropriately resuscitated. However, in hemodynamically unstable cases and when direct signs of aortic injury are present on CT, definitive emergent management of the aortic injury is suggested. By contrast, the SVS recommends urgent (<24 h) repair barring other serious concomitant nonaortic injuries or repair immediately after the treatment of other injuries but before hospital discharge. Anticoagulation with heparin is necessary for either endovascular treatment or open replacement. Definitive management is planned after appropriate bleeding control is achieved in patients with intracranial hemorrhage or other bleeding conditions. Nonoperative therapy, including the use of beta-blockers for aggressive blood pressure control, is applied as a bridge to delayed intervention. Patients without obvious bleeding sources undergoes urgent repair.
Most of our patients underwent endovascular treatment. There are still some situations in which endovascular repair may not appropriate and open repair should be considered as endovascular repair may impede stent deployment and induce more complications in patients with smaller diameter of the thoracic aorta, younger age, tortuous aorta, and complicated aortic anatomy., Without contraindications to endovascular technique, both SVS and EAST guidelines suggest endovascular repair rather than open repair for patients., In this study, two patients underwent chimney stenting, while one patient underwent subclavian-to-subclavian bypass to preserve blood supply in the left arm. Moreover, two patients did not undergo any preventive procedure, although the stent graft was deployed at zone 2 in one patient. Stent graft was deployed at zone 3 in another patient. No limb ischemia was detected after pTEVAR. Proposed indications for revascularization of the left subclavian artery include patent left internal mammary artery to left anterior descending coronary artery bypass or any anatomic variations that necessitate a patent left vertebral artery. Our experience suggests that the left subclavian coverage may be safe in selected patients.
In our series, there were two cases of initial Type 1a endoleak after pTEVAR. CTA examination after discharge revealed spontaneous resolution. Although there are fewer early complications when compared to those observed with open repair, patients who receive pTEVAR may have late complications. Harky et al. analyzed 21 articles that included 578 and 1390 patients who underwent pTEVAR and open repair, respectively, and observed pTEVAR-related complications such as endoleak (7%), stent migration (3%), and conversion to open intervention (3.7%). In the same review, the rate of re-intervention at 1 year was higher in patients who underwent pTEVAR (6.3%) than in open surgery patients (0%), with most re-intervention cases being due to endoleaks. Patients, who required re-intervention, including open repair, re-stenting, and coil embolization, were treated within 24 months of the initial surgery; those who had survived for this time without requiring further treatment were expected to have a re-intervention-free survival. Although endoleaks occasionally occur after pTEVAR, initial observation and imaging follow-up may be appropriate management strategies in such cases. In our study, one patient complained of paraplegia after pTEVAR, which resolved after spinal drainage. Given the lower incidence of spinal cord ischemia (SCI) in cases of pTEVAR (3%) than in open surgery (9%) for aortic trauma, the SVS recommends spinal drainage to be performed only in case of SCI symptoms. In our series, rescue treatment for SCI showed an acceptable outcome.
The major limitation of our series is the limited sample size, which impeded statistical analysis. Second, there was some data loss because of the retrospective study design. Third, most of the patients underwent clinic follow-up for <2 years after repair. Improvements in imaging quality and aggressive posttrauma CTA have allowed earlier detection of more cases of aortic trauma, including MAI. This may allow future studies to yield more evidence regarding the long-term outcomes and optimal management of TBAI, especially MAI.
| Conclusion|| |
Endovascular repair is the first treatment choice for TBAI, with a decrease in perioperative mortality observed recently. Delayed intervention is suggested to stabilize patients with other major trauma types. Although endoleak could occur intraoperatively, it may spontaneously resolve several months after discharge. Routine spinal drainage could be reserved for paraplegia rescue. In selected cases with Grade 2 injury, a complete resolution of intramural hematoma could be achieved by nonoperative treatment.
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Conflicts of interest
There are no conflicts of interest.
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