Kidane Biniam, Parry Neil G, Forbes Thomas L
Division of General Surgery, London Health Sciences Centre & University of Western Ontario, London, Ontario, Canada.
Ann Vasc Surg. 2013 Nov;27(8):1014-9. doi: 10.1016/j.avsg.2012.09.017. Epub 2013 Jun 20.
Blunt thoracic aortic injury (BTAI) is associated with high mortality. Recent Society for Vascular Surgery (SVS) guidelines recommend repair of all but SVS grade I injuries. This study's objective was to retrospectively determine guideline adherence at the authors' trauma center, and its impact on mortality.
A retrospective review of the trauma database at the authors' university-affiliated trauma center identified and graded all BTAIs between 1999 and 2011. Patient demographics, treatment, and outcomes were recorded.
Imaging was available for 52 of 59 (85.2%) patients with BTAI. For these 52 patients, injury distribution was: 14 (27.0%) grade 1; 1 (1.9%) grade 2; 35 (67.3%) grade 3; and 2 (3.8%) grade 4. Nonoperative management was used for 92.8% (13), 100% (1), 34.3% (12), and 0% of grade 1, 2, 3, and 4 injuries, respectively. The operatively managed grade I injury was initially misclassified as grade 3. He was lost to follow-up after discharge. Of the 12 patients with nonoperatively managed grade 3 injuries, 7 (58.3%) died before consideration of endovascular repair and another died early secondary to brain injury. The remaining 4 (11.4%) with nonoperatively managed grade 3 injuries survived to discharge but were lost to follow-up. For grade 3 injuries, endovascular repair was significantly associated with decreased mortality (odds ratio [OR], 0.10; 0.02-0.53; P=0.007). Exclusion of those with presentation-day mortality negated this significant association (OR, 0.84; 0.07-9.68; P=1.00).
Minor deviation (9.6%) from guidelines did not result in additional morbidity/mortality. However, a high rate of loss to follow-up limits conclusions. The mortality reduction seen with endovascular repair for grade 3 injury is inflated by patients who die before repair is considered in the nonoperative group. Larger prospective studies with appropriate inclusion and exclusion criteria and improved follow-up are needed to determine the consequences of selective nonoperative management of these injuries.
钝性胸主动脉损伤（BTAI）与高死亡率相关。血管外科学会（SVS）近期指南建议，除SVS I级损伤外，其他所有损伤均应进行修复。本研究的目的是回顾性确定作者所在创伤中心对指南的遵循情况及其对死亡率的影响。
对作者所在大学附属创伤中心的创伤数据库进行回顾性分析，确定并分级1999年至2011年间所有的BTAI。记录患者的人口统计学资料、治疗情况及预后。
59例BTAI患者中有52例（85.2%）有影像学资料。对于这52例患者，损伤分级分布为：I级14例（27.0%）；II级1例（1.9%）；III级35例（67.3%）；IV级2例（3.8%）。I级、II级、III级和IV级损伤分别有92.8%（13例）、100%（1例）、34.3%（12例）和0%采用非手术治疗。接受手术治疗的I级损伤最初被误分类为III级。该患者出院后失访。在12例接受非手术治疗的III级损伤患者中，7例（58.3%）在考虑进行血管内修复之前死亡，另1例因脑损伤早期死亡。其余4例（11.4%）接受非手术治疗的III级损伤患者存活至出院，但失访。对于III级损伤，血管内修复与死亡率降低显著相关（优势比[OR]，0.10；0.02 - 0.53；P = 0.007）。排除入院当天死亡患者后，这种显著相关性消失（OR，0.84；0.07 - 9.68；P = 1.00）。
与指南的轻微偏差（9.6%）并未导致额外的发病率/死亡率。然而，高失访率限制了结论的得出。非手术组中在考虑修复前死亡的患者使血管内修复治疗III级损伤所带来的死亡率降低效果被夸大。需要开展更大规模的前瞻性研究，制定合适的纳入和排除标准并改善随访，以确定对这些损伤进行选择性非手术治疗的后果。
