Blunt traumatic thoracic aortic injuries: Early or delayed repair - Results of an American Association for the Surgery of Trauma prospective study

Demetrios Demetriades, George C. Velmahos, Thomas M. Scalea, Gregory Jurkovich, Riyad Karmy-Jones, Pedro G. Teixeira, Mark R. Hemmila, James V. O'Connor, Mark O. McKenney, Forrest O. Moore, Jason London, Michael J. Singh, Konstantinos Spaniolas, Marius Keel, Michael Sugrue, Wendy L. Wahl, Jonathan Hill, Mathew J. Wall, Ernest E. Moore, Edward LineenDaniel Margulies, Valerie Malka, Linda S. Chan

Research output: Contribution to journalArticle

103 Citations (Scopus)

Abstract

BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (≤24 hours) and delayed repair groups (>24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.

Original languageEnglish (US)
Pages (from-to)967-973
Number of pages7
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume66
Issue number4
DOIs
StatePublished - Jan 1 2009
Externally publishedYes

Fingerprint

Thoracic Injuries
Prospective Studies
Wounds and Injuries
Nonpenetrating Wounds
Intensive Care Units
Length of Stay
Glasgow Coma Scale
Hypotension
Mortality
Multivariate Analysis
Endovascular Procedures
Injury Severity Score
Survival
Mechanical Ventilators
Blood Transfusion
Multicenter Studies
Observational Studies
Demography

Keywords

  • Early versus delayed repair
  • Outcomes
  • Traumatic thoracic aortic injuries

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Blunt traumatic thoracic aortic injuries : Early or delayed repair - Results of an American Association for the Surgery of Trauma prospective study. / Demetriades, Demetrios; Velmahos, George C.; Scalea, Thomas M.; Jurkovich, Gregory; Karmy-Jones, Riyad; Teixeira, Pedro G.; Hemmila, Mark R.; O'Connor, James V.; McKenney, Mark O.; Moore, Forrest O.; London, Jason; Singh, Michael J.; Spaniolas, Konstantinos; Keel, Marius; Sugrue, Michael; Wahl, Wendy L.; Hill, Jonathan; Wall, Mathew J.; Moore, Ernest E.; Lineen, Edward; Margulies, Daniel; Malka, Valerie; Chan, Linda S.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 66, No. 4, 01.01.2009, p. 967-973.

Research output: Contribution to journalArticle

Demetriades, D, Velmahos, GC, Scalea, TM, Jurkovich, G, Karmy-Jones, R, Teixeira, PG, Hemmila, MR, O'Connor, JV, McKenney, MO, Moore, FO, London, J, Singh, MJ, Spaniolas, K, Keel, M, Sugrue, M, Wahl, WL, Hill, J, Wall, MJ, Moore, EE, Lineen, E, Margulies, D, Malka, V & Chan, LS 2009, 'Blunt traumatic thoracic aortic injuries: Early or delayed repair - Results of an American Association for the Surgery of Trauma prospective study', Journal of Trauma - Injury, Infection and Critical Care, vol. 66, no. 4, pp. 967-973. https://doi.org/10.1097/TA.0b013e31817dc483
Demetriades, Demetrios ; Velmahos, George C. ; Scalea, Thomas M. ; Jurkovich, Gregory ; Karmy-Jones, Riyad ; Teixeira, Pedro G. ; Hemmila, Mark R. ; O'Connor, James V. ; McKenney, Mark O. ; Moore, Forrest O. ; London, Jason ; Singh, Michael J. ; Spaniolas, Konstantinos ; Keel, Marius ; Sugrue, Michael ; Wahl, Wendy L. ; Hill, Jonathan ; Wall, Mathew J. ; Moore, Ernest E. ; Lineen, Edward ; Margulies, Daniel ; Malka, Valerie ; Chan, Linda S. / Blunt traumatic thoracic aortic injuries : Early or delayed repair - Results of an American Association for the Surgery of Trauma prospective study. In: Journal of Trauma - Injury, Infection and Critical Care. 2009 ; Vol. 66, No. 4. pp. 967-973.
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abstract = "BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (≤24 hours) and delayed repair groups (>24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2{\%}) of which underwent early repair and 69 (38.8{\%}) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95{\%} CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.",
keywords = "Early versus delayed repair, Outcomes, Traumatic thoracic aortic injuries",
author = "Demetrios Demetriades and Velmahos, {George C.} and Scalea, {Thomas M.} and Gregory Jurkovich and Riyad Karmy-Jones and Teixeira, {Pedro G.} and Hemmila, {Mark R.} and O'Connor, {James V.} and McKenney, {Mark O.} and Moore, {Forrest O.} and Jason London and Singh, {Michael J.} and Konstantinos Spaniolas and Marius Keel and Michael Sugrue and Wahl, {Wendy L.} and Jonathan Hill and Wall, {Mathew J.} and Moore, {Ernest E.} and Edward Lineen and Daniel Margulies and Valerie Malka and Chan, {Linda S.}",
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TY - JOUR

T1 - Blunt traumatic thoracic aortic injuries

T2 - Early or delayed repair - Results of an American Association for the Surgery of Trauma prospective study

AU - Demetriades, Demetrios

AU - Velmahos, George C.

AU - Scalea, Thomas M.

AU - Jurkovich, Gregory

AU - Karmy-Jones, Riyad

AU - Teixeira, Pedro G.

AU - Hemmila, Mark R.

AU - O'Connor, James V.

AU - McKenney, Mark O.

AU - Moore, Forrest O.

AU - London, Jason

AU - Singh, Michael J.

AU - Spaniolas, Konstantinos

AU - Keel, Marius

AU - Sugrue, Michael

AU - Wahl, Wendy L.

AU - Hill, Jonathan

AU - Wall, Mathew J.

AU - Moore, Ernest E.

AU - Lineen, Edward

AU - Margulies, Daniel

AU - Malka, Valerie

AU - Chan, Linda S.

PY - 2009/1/1

Y1 - 2009/1/1

N2 - BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (≤24 hours) and delayed repair groups (>24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.

AB - BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (≤24 hours) and delayed repair groups (>24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.

KW - Early versus delayed repair

KW - Outcomes

KW - Traumatic thoracic aortic injuries

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