Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries

Results of an American Association for the Surgery of Trauma multicenter 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, Edward Lineen, Konstantinos Spaniolas, Marius Keel, Michael Sugrue, Wendy L. Wahl, Jonathan Hill, Mathew J. Wall, Ernest E. Moore & 3 others Daniel Margulies, Valerie Malka, Linda S. Chan

Research output: Contribution to journalArticle

272 Citations (Scopus)

Abstract

INTRODUCTION: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR). PATIENTS: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score ≤8, systolic blood pressure <90 mm Hg, and age >55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score ≤8, and age >55 years. RESULTS: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (35.2%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers. CONCLUSIONS: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.

Original languageEnglish (US)
Pages (from-to)561-570
Number of pages10
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume64
Issue number3
DOIs
StatePublished - Mar 1 2008
Externally publishedYes

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Thoracic Injuries
Multicenter Studies
Stents
Transplants
Wounds and Injuries
Glasgow Coma Scale
Mortality
Blood Pressure
Craniocerebral Trauma
Blood Transfusion
Equipment and Supplies
Abdomen
Hypotension
Length of Stay
Extremities
Odds Ratio
Endoleak
Aortic Rupture
Endovascular Procedures
Injury Severity Score

Keywords

  • AAST multicenter study
  • Open repair versus endovascular repair
  • Outcomes
  • Traumatic thoracic aorta

ASJC Scopus subject areas

  • Surgery

Cite this

Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries : Results of an American Association for the Surgery of Trauma multicenter 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.; Lineen, Edward; Spaniolas, Konstantinos; Keel, Marius; Sugrue, Michael; Wahl, Wendy L.; Hill, Jonathan; Wall, Mathew J.; Moore, Ernest E.; Margulies, Daniel; Malka, Valerie; Chan, Linda S.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 64, No. 3, 01.03.2008, p. 561-570.

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, Lineen, E, Spaniolas, K, Keel, M, Sugrue, M, Wahl, WL, Hill, J, Wall, MJ, Moore, EE, Margulies, D, Malka, V & Chan, LS 2008, 'Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: Results of an American Association for the Surgery of Trauma multicenter study', Journal of Trauma - Injury, Infection and Critical Care, vol. 64, no. 3, pp. 561-570. https://doi.org/10.1097/TA.0b013e3181641bb3
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. ; Lineen, Edward ; Spaniolas, Konstantinos ; Keel, Marius ; Sugrue, Michael ; Wahl, Wendy L. ; Hill, Jonathan ; Wall, Mathew J. ; Moore, Ernest E. ; Margulies, Daniel ; Malka, Valerie ; Chan, Linda S. / Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries : Results of an American Association for the Surgery of Trauma multicenter study. In: Journal of Trauma - Injury, Infection and Critical Care. 2008 ; Vol. 64, No. 3. pp. 561-570.
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abstract = "INTRODUCTION: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR). PATIENTS: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score ≤8, systolic blood pressure <90 mm Hg, and age >55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score ≤8, and age >55 years. RESULTS: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9{\%}) were selected for SG and 68 (35.2{\%}) for OR. SG was selected in 71.6{\%} of the 74 patients with major extrathoracic injuries and in 60.0{\%} of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0{\%}) developed 32 device-related complications. There were 18 endoleaks (14.4{\%}), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9{\%} in the OR and 0.8{\%} in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95{\%} CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95{\%} CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95{\%} CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95{\%} CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers. CONCLUSIONS: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.",
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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 Edward Lineen 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 Daniel Margulies and Valerie Malka and Chan, {Linda S.}",
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T1 - Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries

T2 - Results of an American Association for the Surgery of Trauma multicenter 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 - Lineen, Edward

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 - Margulies, Daniel

AU - Malka, Valerie

AU - Chan, Linda S.

PY - 2008/3/1

Y1 - 2008/3/1

N2 - INTRODUCTION: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR). PATIENTS: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score ≤8, systolic blood pressure <90 mm Hg, and age >55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score ≤8, and age >55 years. RESULTS: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (35.2%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers. CONCLUSIONS: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.

AB - INTRODUCTION: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR). PATIENTS: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS >3), GCS score ≤8, systolic blood pressure <90 mm Hg, and age >55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS >3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score ≤8, and age >55 years. RESULTS: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (35.2%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value <0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005) than low-volume centers. CONCLUSIONS: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.

KW - AAST multicenter study

KW - Open repair versus endovascular repair

KW - Outcomes

KW - Traumatic thoracic aorta

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