Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis.

We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration. Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking. Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification. Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group. In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Romijn AC ，Rastogi V ，Proaño-Zamudio JA ，Argandykov D ，Marcaccio CL ，Giannakopoulos GF ，Kaafarani HMA ，Jongkind V ，Bloemers FW ，Verhagen HJM ，Schermerhorn ML ，Saillant NN ... -  《-》

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience.

Rahman T ，Halonen LM ，Handolin L ，Juvonen T ，Jormalainen M ，Dahlbacka S ... -  《-》

Clinical presentation, outcomes, and threshold for repair by sex in degenerative saccular vs fusiform aneurysms in the descending thoracic aorta.

Saccular-shaped thoracic aortic aneurysms (TAAs) are often treated at smaller diameters compared with fusiform TAAs, despite a lack of strong clinical evidence to support this practice. The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAAs and fusiform TAAs in the descending thoracic aorta. We also examined the need for sex-specific treatment thresholds for TAAs. All Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for degenerative TAAs in the descending thoracic aorta from 2012 through 2022 were reviewed. Patients were stratified by urgency: emergent/urgent vs elective repairs (ruptured/symptomatic). Demographics, comorbidities, anatomical/procedural characteristics, and outcomes for fusiform TAAs and saccular TAAs were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent emergent/urgent repair according to sex-stratified aortic diameter. Among 655 emergent/urgent TEVARs, 37% were performed for saccular TAAs, whereas among 1352 elective TEVARs, 35% had saccular TAA morphology. Compared with fusiform TAAs, saccular TAAs more frequently underwent emergent/urgent (ruptured/symptomatic) TEVAR below the repair threshold in both females (<50 mm: 38% vs 10%; relative risk, 3.39; 95% confidence interval [CI], 2.04-5.70; P < .001), and males (<55 mm: 47% vs 21%; relative risk, 2.26; 95% CI, 1.60-3.18; P < .001). Moreover, among patients with emergent/urgent fusiform TAAs, females presented at smaller diameters compared with males, whereas there was no difference in preoperative aneurysm diameter among patients with saccular TAAs. Regarding outcomes, emergent/urgent treated saccular TAAs had similar postoperative outcomes and 5-year mortality compared with fusiform TAAs. Nevertheless, in the elective cohort, patients with saccular TAAs had similar postoperative mortality compared with those with fusiform TAAs, but a lower rate of postoperative spinal cord ischemia (0.7% vs 3.2%; P = .010). Furthermore, patients with saccular TAAs had a higher rate of 5-year mortality compared with their fusiform counterparts (23% vs 17%; hazard ratio, 1.53; 95% CI, 1.12-2.10; P = .010). Patients with saccular TAAs underwent emergent/urgent TEVAR at smaller diameters than those with fusiform TAAs, supporting current clinical practice guideline recommendations that saccular TAAs warrant treatment at smaller diameters. Furthermore, these data support a sex-specific treatment threshold for patients with fusiform TAAs, but not for those with saccular TAAs. Although there were no differences in outcomes following TEVAR between morphologies in the emergent/urgent cohort, patients with saccular TAAs who were treated electively were associated with higher 5-year mortality compared with those with fusiform TAAs.

Rastogi V ，Guetter CR ，Patel PB ，Anjorin AC ，Marcaccio CL ，Yadavalli SD ，Scali ST ，Beck AW ，Verhagen HJM ，Schermerhorn ML ... -  《-》

Clinical Frailty Scale Predicts Outcomes After Elective Thoracic Endovascular Aortic Repair: A Single-Center Retrospective Cohort Study.

Tsushima S ，Shibata T ，Iba Y ，Nakajima T ，Nakazawa J ，Miura S ，Arihara A ，Nakanishi K ，Mizuno T ，Mukawa K ，Kawaharada N ... -  《-》

Civilian ballistic spinal cord injuries versus blunt trauma: comparative analysis of clinical characteristics, management, and outcomes.

There are no current guidelines for the management of civilian gunshot wound injuries (GSW) to the spine and patient management often relies on algorithms derived from blunt trauma (BT). However, spinal cord injury due to GSW or blunt trauma mechanism may have significantly different clinical presentation, management, and outcomes. To ensure improved and evidence-based treatment, we need to understand the outcome determining characteristics of civilian GSW to the spine and identify the differences to the well-studied BT. The aim of this study was to compare clinical characteristics, neurological deficit, management strategies, and mortality associated with GSW to the spine versus BT. Retrospective single-center analysis. One thousand nine hundred thirty-nine unique patients admitted to a level 1 trauma center with spinal cord injuries due to GSW or BT between the years 2003-2022. Primary outcome measure was the progression in American Spinal Injury Association (ASIA) motor score. Clinical characteristics were compared followed by age-matched analysis (<45years) of neurological injury, the need for surgery, neurological outcomes and mortality. Stratification by neurological injury allowed for more homogenous subgroups for outcome analysis. Of the 1939 patients with spinal cord injury, 566 were included in GSW group, and 1373 patients in BT group. Most patients in the GSW group were males (94.9% GSW vs 83.5% BT; p<.001) and younger (28.2 (range 13-62) years vs 37.9, (range 12-91) years, p<.001). The age-matched dataset comprised 1536 patients, with 540 in GSW group, and 996 in BT group. There were significantly more complete neurological injuries at admission in GSW group compared with BT (63.5% GSW vs 34.4% BT, p<.001). The ASIA motor Score at admission was significantly lower in GSW group (p<.001), and changed without significant difference between the groups from admission to discharge (p<.001, p=.222). Subgroup analysis based on spinal cord injury showed that a higher proportion of patients with incomplete injuries improved neurologically, opposed to complete injuries, with significantly more patients improving in GSW group compared to BT (incomplete 58.9% GSW vs 44.3% BT, p<.001). Likewise, a higher proportion of paraplegic patients improved, opposed to quadriplegic patients, and in the paraplegic subgroup GSW patients improved rather than BT (paraplegic 65.1% GSW vs 35.3%BT, p<.001). In GSW group significantly less patients were managed operatively compared to BT group (12.2% GSW vs 76.8% BT, p<.001). Most surgeries were bullet removals (81,4%) and involved the lumbar spine: 38.6% lumbar surgeries (of all GSW surgeries) and 31.4% surgery rate of all lumbar GSW patients. There was no significant difference in ASIA motor and sensory score improvement between patients who underwent surgery for bullet removal compared to nonoperatively managed patients in GSW group (p=.199). The incidence rate of surgery showed a downwards trend over the study period. GSW group showed significantly less complications than BT group (22.8% GSW vs 27.0% BT, p<.001). There was no significant difference in mortality rates (p≥.289). To our knowledge, this is the largest single-center dataset of civilian ballistic spinal cord injuries compared to BT. GSW affect mostly young males and result in significantly more severe, complete neurologic injuries compared with BT at similar mortality rates. Nevertheless, the present data suggest a greater potential for neurological improvement for paraplegic patients and incomplete injuries in GSW group. Patients with spinal cord injuries due to GSW undergo surgery less frequently compared to BT. Operated GSW cases primarily involved the lumbar spine. This study revealed differences between spinal cord injuries due to GSW and BT. In clinical application, this means that guidelines based on BT may not directly be transferable to civilian ballistic spinal cord injuries.

Jacob A ，Loibl M ，Kruger S ，Blankson BH ，Zderic I ，Wirtz CR ，Dunn RN ，Kruger NA ... -  《-》