Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
J Vasc Surg. 2018 Jul;68(1):64-73. doi: 10.1016/j.jvs.2017.10.084. Epub 2018 Feb 13.
The traditional approach to stable blunt thoracic aortic injury (BTAI) endorsed by the Society for Vascular Surgery is early (<24 hours) thoracic endovascular aortic repair (TEVAR). Recently, some studies have shown improved mortality in stable BTAI patients repaired in a delayed manner (≥24 hours). However, the indications for use of delayed TEVAR for BTAI are not well characterized, and its overall impact on the patient's survival remains poorly understood. We sought to determine whether delayed TEVAR is associated with a decrease in mortality compared with early TEVAR in this population.
We conducted a retrospective cohort study of adult patients with BTAI (International Classification of Diseases, Ninth Revision diagnosis code 901.0) who underwent TEVAR (International Classification of Diseases, Ninth Revision procedure code 39.73) from 2009 to 2013 using the National Sample Program data set. Missing physiologic data were imputed using chained multiple imputation. Patients were parsed into groups based on the timing of TEVAR (early, <24 hours, vs delayed, ≥24 hours). The χ, Mann-Whitney, and Fisher exact tests were used to compare baseline characteristics and outcomes of interest between groups. Multivariable logistic regression for mortality was performed that included all variables significant at P ≤ .2 in univariate analyses.
A total of 2045 adult patients with BTAI were identified, of whom 534 (26%) underwent TEVAR. Patients with missing data on TEVAR timing were excluded (n = 27), leaving a total of 507 patients for analysis (75% male; 69% white; median age, 40 years [interquartile range, 27-56 years]; median Injury Severity Score [ISS], 34 [interquartile range, 26-41]). Of these, 378 patients underwent early TEVAR and 129 underwent delayed TEVAR. The two groups were similar with regard to age, sex, race, ISS, and presenting physiology. Mortality was 11.9% in the early TEVAR group vs 5.4% in the delayed group, with the early group displaying a higher odds of death (odds ratio, 2.36; 95% confidence interval, 1.03-5.36; P = .042). After adjustment for age, ISS, and admission physiology, the association between early TEVAR and mortality was preserved (adjusted odds ratio, 2.39; 95% confidence interval, 1.01-5.67; P = .047).
Consistent with current Society for Vascular Surgery recommendations, more BTAI patients underwent early TEVAR than delayed TEVAR during the study period. However, delayed TEVAR was associated with significantly reduced mortality in this population. Together, these findings support a need for critical appraisal and clarification of existing practice guidelines in management of BTAI. Future studies should seek to understand this survival disparity and to determine optimal selection of patients for early vs delayed TEVAR.
血管外科学会支持的传统稳定钝性胸主动脉损伤（BTAI）治疗方法是早期（<24 小时）胸主动脉腔内修复术（TEVAR）。最近，一些研究表明，稳定的 BTAI 患者采用延迟（≥24 小时）方式进行修复可降低死亡率。然而，BTAI 采用延迟 TEVAR 的指征尚未明确，其对患者生存的总体影响仍知之甚少。我们旨在确定在该人群中，与早期 TEVAR 相比，延迟 TEVAR 是否与死亡率降低相关。
我们使用国家样本计划数据集，对 2009 年至 2013 年间接受 TEVAR（国际疾病分类，第 9 版手术编码 39.73）的 BTAI（国际疾病分类，第 9 版诊断编码 901.0）成年患者进行了回顾性队列研究。使用链式多重插补法填补缺失的生理数据。根据 TEVAR 的时间（早期，<24 小时，与延迟，≥24 小时）将患者分为两组。使用 χ²、Mann-Whitney 和 Fisher 确切检验比较组间的基线特征和感兴趣的结局。采用多变量逻辑回归进行死亡率分析，纳入单变量分析中 P≤.2 的所有有统计学意义的变量。
共确定了 2045 例 BTAI 成年患者，其中 534 例（26%）接受了 TEVAR。排除了 TEVAR 时间数据缺失的患者（n=27），共纳入 507 例患者进行分析（75%为男性；69%为白人；中位年龄为 40 岁[四分位距 27-56 岁]；中位损伤严重程度评分[ISS]为 34[四分位距 26-41]）。其中，378 例患者接受了早期 TEVAR，129 例患者接受了延迟 TEVAR。两组在年龄、性别、种族、ISS 和入院生理状态方面相似。早期 TEVAR 组死亡率为 11.9%，延迟 TEVAR 组为 5.4%，早期组死亡的可能性更高（比值比，2.36；95%置信区间，1.03-5.36；P=0.042）。在调整年龄、ISS 和入院生理状态后，早期 TEVAR 与死亡率之间的关联仍然存在（调整比值比，2.39；95%置信区间，1.01-5.67；P=0.047）。
与当前血管外科学会的建议一致，在研究期间，更多的 BTAI 患者接受了早期 TEVAR 而非延迟 TEVAR。然而，在该人群中，延迟 TEVAR 与死亡率显著降低相关。这些发现共同支持对管理 BTAI 的现有实践指南进行批判性评估和澄清的必要性。未来的研究应致力于了解这种生存差异，并确定早期和延迟 TEVAR 治疗的最佳患者选择。
