Reed Amy B, Thompson J Keith, Crafton Charles J, Delvecchio Cindy, Giglia Joseph S
Division of Vascular Surgery, University of Cincinnati Medical Center, Ohio 45267, USA.
J Vasc Surg. 2006 Apr;43(4):684-8. doi: 10.1016/j.jvs.2005.12.006.
Patients with blunt traumatic thoracic aortic transection (BTTAT) just distal to the takeoff of the left subclavian artery typically have concomitant injuries that make open emergent surgical repair highly risky. Over the past decade, endovascular repair of the injured thoracic aorta with commercially available and custom-made covered stents has developed as a viable option, with reported decreases in short-term morbidity and mortality. If active extravasation of contrast from the injured thoracic aorta is not appreciated on chest computed tomography scan, other concurrent injuries of the head, abdomen, and extremities can often be repaired with careful control of blood pressure. The timing of endovascular repair of the traumatic thoracic aortic transection, however, often comes into question, particularly with the presence of fever, pneumonia, or bacteremia. We sought to identify a time frame during which endovascular repair of BTTAT could safely be performed.
Age, concomitant injuries, time from trauma to repair, type of device, and major outcomes were recorded.
Over a 5-year period (January 2000 to March 2005), 51 patients presented with BTTAT. Twenty-seven (52.9%) patients with BTTAT died shortly after arrival. Of the remaining 24, 9 underwent emergent open repair, with 1 intraoperative death. Two delayed open repairs were performed. Thirteen patients with BTTAT underwent delayed endovascular repair. Successful endovascular repair of BTTAT was performed in all 13 patients, with no intraoperative deaths. Seven patients were treated with commercial devices and six with custom-made covered stents. None of the repairs was performed emergently. The timing of repair ranged from 1 day to 7 months (median, 6 days), and all patients were treated aggressively with beta-blockade before surgery. One patient was discharged from the hospital and underwent elective repair at a later date. Three patients died in the postoperative period (30 days): two from multisystem organ failure and one from iliac artery complications encountered at the time of device deployment. The remaining 10 patients were successfully discharged to a rehabilitation facility.
The opportunity to successfully perform endovascular repair of BTTAT may be possible many days after the initial injury in the hemodynamically stable trauma patient.
钝性创伤性胸主动脉横断伤（BTTAT）发生于左锁骨下动脉起始部远端的患者通常伴有其他损伤，这使得急诊开放性手术修复风险极高。在过去十年中，使用市售及定制覆膜支架对损伤的胸主动脉进行血管腔内修复已成为一种可行的选择，据报道短期发病率和死亡率有所降低。如果胸部计算机断层扫描未发现损伤的胸主动脉有造影剂外渗，在严格控制血压的情况下，头部、腹部和四肢的其他并发损伤通常可以得到修复。然而，创伤性胸主动脉横断伤的血管腔内修复时机常常受到质疑，尤其是在存在发热、肺炎或菌血症的情况下。我们试图确定一个能安全进行BTTAT血管腔内修复的时间范围。
记录患者年龄、并发损伤、从创伤到修复的时间、所用器械类型及主要结局。
在5年期间（2000年1月至2005年3月），51例患者出现BTTAT。27例（52.9%）BTTAT患者在到达后不久死亡。其余24例中，9例接受了急诊开放性修复，其中1例术中死亡。进行了2例延迟开放性修复。13例BTTAT患者接受了延迟血管腔内修复。所有13例患者的BTTAT血管腔内修复均成功，无术中死亡。7例患者使用市售器械治疗，6例使用定制覆膜支架治疗。所有修复均非急诊进行。修复时间从1天至7个月不等（中位数为6天），所有患者在手术前均积极接受β受体阻滞剂治疗。1例患者出院，之后接受了择期修复。3例患者在术后30天内死亡：2例死于多系统器官衰竭，1例死于器械置入时出现的髂动脉并发症。其余10例患者成功出院并转入康复机构。
对于血流动力学稳定的创伤患者，在初次受伤数天后仍有可能成功进行BTTAT的血管腔内修复。
