钝性胸主动脉损伤治疗的进展改善了预后：一项西部创伤协会多中心研究
The evolution of care improves outcome in blunt thoracic aortic injury: A Western Trauma Association multicenter study.
作者信息
Shackford Steven R, Dunne Casey E, Karmy-Jones Riyad, Long William, Teso Desarom, Schreiber Martin A, Watson Justin, Watson Cheri, McIntyre Robert C, Ferrigno Lisa, Shapiro Mark L, Southerland Kevin, Dunn Julie A, Reckard Paul, Scalea Thomas M, Brenner Megan, Teeter William A
机构信息
From the Trauma Service (S.R.S., C.E.D.), Scripps Mercy Hospital, San Diego, California; Trauma and Acute Care Surgery Service (R.K.-J., W.L.), Legacy Emanuel Medical Center, Portland, Oregon; Division of Vascular Surgery (R.K.-J., D.T.), PeaceHealth Southwest Washington Medical Center, Vancouver, Washington; Division of Trauma (M.A.S., J.W., C.W.), Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon; Department of Surgery (R.C.M., L.F.), University of Colorado Denver School of Medicine, Aurora, Colorado; Division of Trauma (M.L.S., K.S.), Duke University Medical Center, Durham, North Carolina; UC Health Medical Center of the Rockies (J.A.D., P.R.), Loveland, Colorado; and R Adams Cowley Shock Trauma Center (T.M.S., M.B., W.A.T.), University of Maryland School of Medicine, Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2017 Dec;83(6):1006-1013. doi: 10.1097/TA.0000000000001555.
BACKGROUND
The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular aortic repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI.
METHODS
Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between January 1, 2006, and June 30, 2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome.
RESULTS
We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). Thoracic endovascular aortic repair and open repair groups had similar Injury Severity Scale score, chest Abbreviated Injury Scale score, Trauma and Injury Severity Score, and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}, 19-51]; TEVAR: 46 [IQR, 28-60]; p < 0.007), zone of aortic injury (p < 0.001), and grade of aortic injury (open: 6 [IQR, 4-6]; TEVAR: 2 [IQR, 2-4]; p < 0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%; p = 0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%.
CONCLUSIONS
The mortality of BTAI continues to decrease. Thoracic endovascular aortic repair, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in computed tomography imaging in follow-up of TEVAR is warranted.
LEVEL OF EVIDENCE
Therapeutic/care management, level III.
背景
在过去十年中，钝性胸主动脉损伤（BTAI）的治疗方法随着护理流程的改变和胸主动脉腔内修复术（TEVAR）的引入而发生了根本性的演变。这些改变带来了更好的治疗效果，但由于先前的研究缺乏有力的风险调整和长期随访，TEVAR对治疗效果的直接影响仍存在疑问。为了填补这些知识空白，我们比较了TEVAR、开放手术修复和非手术治疗BTAI的效果。
方法
从西部创伤协会多中心研究组招募的8个经过验证的创伤中心，对2006年1月1日至2016年6月30日期间收治的所有BTAI患者进行了回顾性研究。数据包括人口统计学、合并症、入院时的生理状况、损伤严重程度、住院治疗情况和治疗效果。
结果
我们研究了316例BTAI患者；57例（18.0%）病情危急，在治疗前死亡。在259例接受手术治疗的患者中，176例（68.0%）接受了TEVAR治疗，28例（10.8%）接受了开放手术，4例（1.5%）接受了杂交手术，51例（19.7%）接受了非手术治疗。胸主动脉腔内修复组和开放修复组的损伤严重程度评分、胸部简明损伤评分、创伤和损伤严重程度评分以及生存概率相似，但中位年龄不同（开放手术组：28岁[四分位间距{IQR}，19 - 51岁]；TEVAR组：46岁[IQR，28 - 60岁]；p < 0.007），主动脉损伤部位不同（p < = 0.001），主动脉损伤分级不同（开放手术组：6级[IQR，4 - 6级]；TEVAR组：2级[IQR，2 - 4级]；p < 0.001）。总体住院死亡率为6.6%（TEVAR组：5.7%，开放手术组：10.7%，非手术治疗组：3.9%；p = 0.535）。在240例存活至出院的患者中，2例死亡（1例在9个月时死亡，1例在8年时死亡）；这2例均接受了TEVAR治疗，但死亡与主动脉手术无关。37.6%的患者未进行支架移植物监测计算机断层扫描。
结论
BTAI的死亡率持续下降。在解剖结构合适时，胸主动脉腔内修复术应作为首选治疗方法。对于更靠近近端的损伤，开放修复仍然是必要的。有必要改进TEVAR随访中的计算机断层扫描成像流程。
证据水平
治疗/护理管理，III级。
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