Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
Division of Vascular Surgery, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Md.
J Vasc Surg. 2022 Mar;75(3):930-938. doi: 10.1016/j.jvs.2021.09.028. Epub 2021 Oct 1.
BACKGROUND: Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy. METHODS: The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (<6 vs ≥6 hours) or urgent (<24 vs ≥24 hours) intervals. RESULTS: A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (<6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (<24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke. CONCLUSIONS: In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.
背景：颅脑创伤（TBI）和钝性胸主动脉损伤（BTAI）是钝性创伤后导致死亡的前两大原因。同时存在 BTAI 和 TBI 的患者在治疗策略方面存在特殊挑战，因为这两种疾病的最佳血流动力学参数相互冲突。早期进行胸主动脉腔内修复术（TEVAR）通常用于治疗最小的主动脉损伤，以允许 TBI 管理所需的更高血压参数。然而，同时存在 TBI 的患者中，治疗 BTAI 的 TEVAR 的最佳时机仍然是一个活跃的争议问题。
方法：使用主动脉创伤基金会国际前瞻性多中心登记处，确定了 2015 年至 2020 年间 TBI 患者中因 BTAI 而行 TEVAR 的所有患者。主要结局包括迟发性缺血性或出血性脑卒中、住院死亡率和主动脉相关死亡率。检查了在紧急（<6 小时 vs ≥6 小时）或紧急（<24 小时 vs ≥24 小时）间隔进行 TEVAR 的患者的结局。
结果：共确定了 100 例（中位年龄 43 岁；79%为男性；中位损伤严重程度评分 41）同时存在 BTAI（美国血管外科学会 BTAI 分级 1 级，3%；2 级，10%；3 级，78%；4 级，9%）和 TBI 并接受 TEVAR 的患者。51 例（51%）患者进行了急诊修复。与紧急修复（<6 小时）相比，紧急修复（≥6 小时）在迟发性脑缺血事件（2.0% vs 4.1%；P=.614）、住院死亡率（15.7% vs 22.4%；P=.389）或主动脉相关死亡率（2.0% vs 2.0%；P=.996）方面无差异，且无患者发生迟发性出血性脑卒中。同样，在紧急（<24 小时）情况下进行的修复与在紧急（≥24 小时）情况下进行的修复相比，在迟发性缺血性脑卒中（2.6% vs 4.3%；P=.548）、住院死亡率（18.2% vs 21.7%；P=.764）或主动脉相关死亡率（1.3% vs 4.3%；P=.654）方面无差异，且无患者发生迟发性出血性脑卒中。
结论：与之前的回顾性研究相比，主动脉创伤基金会国际前瞻性多中心登记处的结果表明，同时存在 BTAI 和 TBI 的患者行紧急或紧急 TEVAR 均与迟发性脑卒中、住院死亡率或主动脉相关死亡率无关。在这些患者中，TEVAR 的时机对结局没有影响。因此，干预决策应根据患者个体因素而非手术时机来指导。
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