Arthurs Zachary M, Starnes Benjamin W, Sohn Vance Y, Singh Niten, Martin Matthew J, Andersen Charles A
Department of Surgery, Madigan Army Medical Center, Tacoma, Wash, USA.
J Vasc Surg. 2009 Apr;49(4):988-94. doi: 10.1016/j.jvs.2008.11.052.
Blunt thoracic aortic injury (BAI) remains a leading cause of trauma deaths, and off-label use of endovascular devices has been increasingly utilized in an effort to reduce the morbidity and mortality in this population. Utilizing a nationwide database, we determined the incidence of BAI, and analyzed both functional and survival outcomes at discharge compared with matched controls.
Patients with BAI were identified by International Classification of Disease-9 codes from the National Trauma Data Bank (Version 6.2), 2000-2005. Patients were analyzed based on aortic repair, associated physiologic burden, and coexisting injuries. Control groups were matched by age, mechanism, major thoracic Abbreviated Injury Scale score (AIS >/= 3), major head AIS, and major abdominal AIS. Outcomes were assessed using the functional independence measure (FIM) score and overall mortality. FIM scores were scored from 1 (full assistance required) to 4 (fully independent) for three categories: feeding, locomotion, and expression.
During the study period, 3,114 patients with BAI were identified among 1.1 million trauma admissions for an overall incidence of 0.3%. One hundred thirteen (4%) were dead on arrival, and 599 (19%) died during triage. Of the patients surviving transport and triage (n = 2402), 29% had a concomitant major abdominal injury and 31% had a major head injury. Sixty-eight percent (1,642) underwent no repair, 28% (665) open aortic repair, and 4% (95) endovascular repair with associated mortality rates of 65%, 19%, and 18%, respectively (P < .05). Aortic repair independently improved survival when controlling for associated injuries and physiologic burden (odds ratio (OR) = 0.36; 95% confidence interval (CI), 0.24-0.54, P < .05). Compared with matched controls, BAI resulted in a higher mortality (55% vs. 15%, P < .05), and independently contributed to mortality (OR = 4.04; 95% CI, 3.53-4.63, P < .05). In addition, BAI patients were less likely to be fully independent for feeding (72% vs. 82%, P < .05), locomotion (33% vs. 55%, P < .05), and expression (80% vs 88%, P < .05).
This manuscript is the first to define the incidence of BAI utilizing the NTDB. Remarkably, two-thirds of patients are unable to undergo attempts at aortic repair, which portends a poor prognosis. When controlling for associated injuries, blunt aortic injury independently impacts survival and results in poor function in those surviving to discharge.
钝性胸主动脉损伤（BAI）仍然是创伤死亡的主要原因，非标签使用血管内装置已越来越多地被用于降低该人群的发病率和死亡率。利用全国性数据库，我们确定了BAI的发病率，并分析了出院时与匹配对照组相比的功能和生存结局。
通过国际疾病分类第9版编码，从2000 - 2005年国家创伤数据库（第6.2版）中识别出BAI患者。根据主动脉修复情况、相关生理负担和并存损伤对患者进行分析。对照组按年龄、受伤机制、主要胸部简明损伤量表评分（AIS≥3）、主要头部AIS和主要腹部AIS进行匹配。使用功能独立性测量（FIM）评分和总体死亡率评估结局。FIM评分从1（需要完全协助）到4（完全独立），分为进食、移动和表达三个类别。
在研究期间，110万例创伤入院患者中识别出3114例BAI患者，总体发病率为0.3%。113例（4%）患者入院时已死亡，599例（19%）在分诊期间死亡。在存活至转运和分诊的患者（n = 2402）中，29%伴有主要腹部损伤，31%伴有主要头部损伤。68%（1642例）未进行修复，28%（665例）接受开放性主动脉修复，4%（95例）接受血管内修复，相关死亡率分别为65%、19%和18%（P <.05）。在控制相关损伤和生理负担时，主动脉修复独立改善了生存率（优势比（OR）= 0.36；95%置信区间（CI），0.24 - 0.54，P <.05）。与匹配对照组相比，BAI导致更高的死亡率（55%对15%，P <.05），并独立导致死亡（OR = 4.04；95% CI，3.53 - 4.63，P <.05）。此外，BAI患者在进食（72%对82%，P <.05）、移动（33%对55%，P <.05）和表达（80%对88%，P <.05）方面完全独立的可能性较小。
本研究首次利用国家创伤数据库定义了BAI的发病率。值得注意的是，三分之二的患者无法尝试进行主动脉修复，这预示着预后不良。在控制相关损伤时，钝性主动脉损伤独立影响生存率，并导致存活至出院的患者功能不良。
