Trauma and Vascular Surgery Section, Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar.
Eur J Trauma Emerg Surg. 2022 Oct;48(5):4079-4091. doi: 10.1007/s00068-022-01930-1. Epub 2022 Mar 14.
Blunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center.
We conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan-Meier curve and Cox regression analysis were performed for the outcome.
Eighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I-IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I-II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001).
BTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.
钝性胸主动脉损伤（BTAI）是钝性创伤患者中仅次于头部损伤的第二大死亡原因。关于中东地区 BTAI 的表现、治疗和结果的信息很少。我们在一级创伤中心探讨了 BTAI 的模式、治疗选择和结果。
我们对 2000 年至 2020 年间因 BTAI 入院的所有成年患者进行了回顾性观察性研究。比较了保守治疗与血管内主动脉修复（TEVAR）和开放手术治疗的管理选择和结果。使用单因素方差分析比较连续变量，使用 Pearson 卡方检验比较分类变量。采用 Kaplan-Meier 曲线和 Cox 回归分析进行结果分析。
87 例患者发生 BTAI（82%为男性），平均年龄 37.3±14.5 岁。平均损伤严重程度评分 30±10，主动脉损伤分级为 III（I-IV）。III 级（41.4%）和 IV 级（33.3%）损伤更为常见，其次是 II 级（13.8%）和 I 级（11.5%）。40%的病例接受保守治疗，60%的病例（n=52）进行了主动脉介入治疗。33 例（63.5%）患者行 TEVAR，19 例（36.5%）患者行开放手术（14 例行移植介入，5 例行夹闭和直接修复）。与保守组相比，介入组的主动脉损伤分级明显更高（p=0.001）。IV 级损伤患者更有可能接受开放修复，而 III 级损伤患者更有可能接受 TEVAR 治疗（p=0.001）。所有 I-II 级损伤患者均接受保守治疗。总的院内死亡率为 25.3%，保守组（40.0%）明显高于开放手术组（31.6%）和 TEVAR 组（6.1%）（P=0.004）。更多的非幸存者遭受了头部损伤（P=0.004），ISS 更高（P=0.001），主动脉损伤分级更高（P=0.002），并且接受了非手术治疗（P=0.001）。
BTAI 在创伤中似乎并不常见，但在一级创伤中心有四分之一的患者死亡，未分析院前死亡，且缺乏尸检。相关的头部损伤和主动脉损伤分级对治疗选择和医院结果有影响。在 78%的病例中，保守和 TEVAR 治疗的选择几乎相等。TEVAR 和开放手术仅用于 III 级或 IV 级主动脉损伤，而对于 4 级损伤中的选定病例，则提供保守治疗。然而，保守治疗组的死亡率高于开放手术组，主要是由于严重的头部损伤。除非因技术困难而不适合，否则应考虑对需要介入治疗的患者进行 TEVAR。适当选择低级别损伤的患者可能可以进行保守治疗。需要对年轻成年人进行长期随访，以关注主动脉重塑和并发症。
