Four-year Surgical Results for Traumatic Aortic Injury in China Medical University Hospital, Mid-Taiwan
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1 Four-year Surgical Results for Traumatic Aortic Injury in China Medical University Hospital, Mid-Taiwan Yi-Chun Lin 林怡均 (5 th grade medical student), MingLi Li 李明禮, Chih-Hsiang Hsu, Ching-Feng Wu, Hui-Han Lin Cardiovascular Division, Surgery Department, China Medical University Hospital, Taichung City, Taiwan LINC Asian-pacific 2019 Hong Kong March 12(Tue)-13(Wed) 2019
2 Disclosure Speaker name: Yi-Chun Lin... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
![Background Blunt traumatic aortic injury (BTAI) carries a high mortality rate up to 10-30% [1] Urgent TEVAR is mandatory for Grade II to IV blunt traumatic aortic injuries.](/docs-images/95/122509143/images/3-0.jpg "[2] Grade I : intimal tear/flap Grade II : intramural hematoma Grade II : AORTIC DISSECTION Grade III : pseudoaneurysm Grade IV: rupture Grade X : PERIAORTIC HEMATOMA Endovascular Today 2014, 38-42.")
3 Background Blunt traumatic aortic injury (BTAI) carries a high mortality rate up to 10-30% [1] Urgent TEVAR is mandatory for Grade II to IV blunt traumatic aortic injuries. [2] Grade I : intimal tear/flap Grade II : intramural hematoma Grade II : AORTIC DISSECTION Grade III : pseudoaneurysm Grade IV: rupture Grade X : PERIAORTIC HEMATOMA Endovascular Today 2014, [1] Aorta, July 2013, Vol.1, Issue 2: [2] Journal of Vascular Surgery 2009, Vol.49,
4 Aim 1. Accuracy of BTAI diagnosis and grading 2. Surgical strategy and results in our center 3. Analysis of mortality causes, complications and reinterventions 4. Aortic remodeling after TEVAR
5 Method Jan Jan all patients performed TEVAR for BTAI. Retrospective review of Initial data Operative Data Post-operation Diagnostic data Mechanism of injury Operation time Length of ICU stay Grade of aortic injury Associated injury Number of stents Length of ward stay Pre-operative CXR Injury severity score Tapered stent usage Early complication Pre-operative CT Glasgow coma scale Diameter of stents Late complication CT after operation Initial / lowest BP Proximal landing Early reintervention False lumen thrombosis Initial heart rate Proximal landing Late reintervention Change of aortic diameter Comorbidity LSCA coverage Mortality cause Door to operation time Associated operation Operation to mortality time BP: blood pressure LSCA: left subclavian artery ICU: intensive care unit CXR: chest X-ray CT: computed tomography
6 False Lumen Thrombosis
7 BTAI Grading 43 BTAI Gr 2 Gr 2 Gr 3 Gr 4 Gr X 1 Type A IMH 4 Type B IMH 4 Type A dissection 7 Type B dissection 15 Pseudoaneurysm 8 Contained rupture 4 Periaortic hematoma IMH: intramural hematoma
8 Periaortic hematoma 17 y/o Male scooter vs car 17 y/o Male scooter vs car 22 y/o Male scooter vs car 72 y/o Male car vs electric pole
9 Pre-operative Results Injury Severity Score (ISS): 31±9 Bike Crash 2% Car Crash 12% Pedestrian 7% Other: hit by electric cable 2% Facial bone Pelvis Spine Extremity Motorcycle Crash 54% Fall 23% Brain Abdomen Sternal and Ribs Lung 28 Mechanism of Injury PERSON Associated Injury
10 Pre-operative Results Apical cap Compression of bronchus Lung contusion Tracheal compression Traumatic pulmonary edema Deviation of NG Hemothorax Age 52.8 ± 17.6 Male 34 (79.07%) Comorbidities Hypertension 15 (34.88%) Cigarette 13 (30.23%) CVA 1 (2.33%) Pleural effusion 5 DM 7 (16.28%) cardiomegaly 6 Medication Ribs/Clavical/Scapula fracture Deviation of trachea 9 11 Antiplatelet 2 (4.65%) Indistinct aortic knob 37 Widened mediastinum 37 Pre-operation CXR
11 Door to Operation Time
12 Operation BTAI (43) BAAD (46) Age 52.8 ± ± 13.3 Operation time min min Number of graft 2 (64.3%) 2 (71.7%) Tapered graft 37.5% 26.1% Proximal diameter 28 mm (34.5%) 34 mm (26.1%) Distal diameter 24 mm (30%) 28 mm (39.1%) Proximal landing Zone3 (52.4%) Zone2 (52.2%) Distal landing T8 (26.8%) / T9 (22.0%) T8 (56.5%) Management of LSA coverage 23.8% TAE 2 / rchim 6 / achim 1/ fenestration 1/ covered % TAE 2/ rchim 18/ achim 3/ fenestration 1/ ligate 1 BAAD: acute Type B aortic dissection TAE: trans-arterial embolization rchim: reversed chimney achim: antegrade chimney
13 Associated Procedure & Combined Surgery CPCR 3 Exploratory laparotomy 10 ECMO 2 Limb ORIF 10 CSF drainage 2 ICP monitor 8 PTA 1 EVD 2 LCCA chimney 1 Craniectomy 2 INMA chimney 2 Craniotomy 2 RSA chimney 1 Bowel resection 1 Fenestration of arch land 1 Splenectomy 1
14 Surgical Results BTAI BAAD 30-day Mortality 13/43 (30.2%) 4/46 (8.7%) Procedure-related 5/43 (11.6%) (free rupture 3) 2/46 (4.3%) Brain injury 5/43 (11.6%) 2/46 (4.3%) Lung 1/43 (2.3%) Tension pneumothorax 1 0 Abdomen Early complication Reintervention 2/43 (4.7%) Visceral ischemia 1/Intraabdominal bleeding 1 7.1% Type A AD with aortic valve entrapment 1 Type A AD AKI % RSA to LSA due to LSA steal syndrome % 23.9 %
15 Analysis of Mortality Grade A IMH Gr II Gr II' Gr III Gr IV Gr X B IMH Type A AD Type B AD Pseudoaneurysm Contained rupture Periaortic hematoma Mortality no. 1 / 1 1 / 4 3 / 4 2 / 7 2 /15 4 /8 0 Type Management Outcome / mortality cause Pre-operative spinal shock, A IMH Z4 TEVAR mortality medulla infarction MBD in 26 day, A AD Asc. Ao grafting + Z3 TEVAR persistent patent false lumen at arch Severe AR, related to A AD Z0 TEVAR mortality aortic valve entrapment Total arch replacement + Z2 Pre-operative cerebellum A AD mortality TEVAR + LSCA achimney infarction A AD Z0 TEVAR +INMA rchimney mortality True lumen collapse
16 A 79 y/o female falling from stairs Gr II Type B IMH
17 A 59 y/o male falling from 2 nd floor Gr II Type A Aortic Dissection Gr4 AR
18 A 42 y/o male with motor-vehicle-crash Gr IV Contained rupture
19 False Lumen Thrombosis Gr II Gr II' Gr III Gr IV Gr X Grade IMH AD Pseudoaneurysm Contained Rupture Periaortic hematoma Follow-up person a % I % IIb % III 100% 16.7% 100% 100% 100%
20 Discussion Correlations Injury severity score (Japan 2010) Traumatic brain injury (USA registry 2017) Mortality rate In this study Literature study 30.2% when ISS % when ISS % % TEVAR for ascending aorta pathology Traumatic 80% Non-traumatic 8.3% [3] J Trauma 2010 Feb;68(2): [4] J Surg Res Nov,219:77-71 [5] J Thoracic and Cardiovascular Surgery 2017 Feb; Volume 153, 2
21 Conclusion 1. Disrupted intercostal arteries, azygos vein and IVC may mimic BTAI 2. TEVAR for BTAI is always a dilemma in multiple traumatic patients 3. Strategy for BTAI with ascending aortic pathology needs further evaluation 4. Promising aortic remodeling for Gr III-IV BTAI after TEVAR procedure
22 Thank you for your attention Yi-Chun Lin 林怡均, MingLi Li 李明禮, Cardiovascular Division, Surgery Department, China Medical University Hospital, Taichung City, Taiwan LINC Asian-pacific 2019 Hong Kong March 12(Tue)-13(Wed) 2019
I-Hui Wu, M.D. Ph.D. Clinical Assistant Professor Cardiovascular Surgical Department National Taiwan University Hospital
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