Outcomes of operative and nonoperative management of blunt thoracic aortic injury
Outcomes of operative and nonoperative management of blunt thoracic aortic injury
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DOI：
10.1016/j.jvs.2022.03.012
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发表时间：
2022-07-01
影响因子：
4.3
通讯作者：
Eslami, Mohammad H.
中科院分区：
文献类型：
--
作者：
Madigan, Michael C.;Lewis, Anthony J.;Eslami, Mohammad H.
目的：尽管目前的钝性创伤性主动脉损伤（BTAI）管理指南建议对2级或更高级别的损伤进行干预，但对低级别BTAI进行积极的血管内治疗已成为全国趋势。关于1级和2级损伤的非手术治疗的自然史知之甚少。我们假设，大多数这些低级别的损伤将保持稳定的非手术management.Methods：我们进行了一项审查的BTAIs在一个大型转诊1级创伤中心，从2004年至2020年。使用标准的1至4级量表对损伤进行分级。比较了非手术和胸主动脉腔内修复术（TEVAR）治疗策略的结局，包括创伤后发病率、死亡率、再次介入和病变稳定性。在研究期间，共确定了176例BTAI患者，并提供了足够的影像学检查和随访数据，其中36例为1级，24例为2级，115例为3级，1例4级损伤。在这176例患者中，112例接受了TEVAR，64例接受了非手术治疗。接受TEVAR的大多数患者（90.2%）有3级损伤。97.2%的1级损伤和62.5%的2级损伤进行了非手术治疗。TEVAR后血管内再介入罕见（2.7%）。创伤后30天内的发病率（中风，3.6% vs 3.1%;心肌梗死/心律失常，8.9% vs 1.6%;呼吸衰竭，31.2% vs 28.1%;急性肾损伤，9.8% vs 12.5%;尿路感染，2.7% vs 4.8%;消化道出血，3.6% vs 0.0%;肺栓塞（10.9% vs 4.5%）和出院后1年死亡率（1.8% vs 3.1%）在手术组和非手术组之间具有可比性。TEVAR组的中位随访时间为1501天（四分位距[IQR]，475.6-2804天），非手术组为1170.5天（IQR，317-2173天）。非手术治疗的轻度（1-2级）损伤患者未发生病变进展。在30天时，20%的患者发生了1级和2级损伤的缓解，在长期随访时改善至44%。还观察到14例3级损伤患者（占我们系列中3级损伤的12.2%），不需要进一步干预。这些患者通常有较小的假性动脉瘤，伴有极轻微的主动脉周围血肿。这14例患者在随访期间（中位数，454.5天; IQR，81-1199天）没有经历进展或破裂使用computedtomography.Conclusions：非手术治疗低级别BTAIs不会导致长期的主动脉并发症或需要再次干预。我们发现，如果患者能够进行适当的随访，可以安全地观察到3级损伤伴较小的假性动脉瘤和极轻微的主动脉周围血肿。因此，选择3级损伤的治疗适应症值得进一步考虑。
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.