How Did We Get To The? CT Scan Granularity & Development of TAVER Multi & Single Center Reports Getting Us Closer to Answer
# Patients Dying That anyone survives complete transection of this artery is almost unbelievable Parmley,LF Circ,June 1958 101 DOA 24 ALIVE Isthmus Rupture 3 3 3 3 3 2 2 1 1 1 <1H 1<6 H 6-<24H 1-2D 3-4D 5-7D 8-14D 15D-3M 4-12M 2-3Y
1971-2001 219 Patients 3 Eras
AAST II 2008-13 9 Level 1 Trauma Ctrs. ISS: 35.6 v 42.4 TAVER V. OPEN 453 BTAI Pts. Mediastinial Treatment Hematoma: Non-Random 26 v 51% NOM(91),TAVER(198), OPEN(61) prbc : 0 v 3 units Hosp Mortality: 8.6 v. 19.7%(all cause) 2.5 v. 13.1%(aortic) DuBose,JTraumaAcute Care Surg 2015;78:360-369
CT Replaces Angiography AATS 1 (1998) vs. AATS 2 (2008) 8.3% vs. 84.4%
Lesions Grades Azizzadeh,J Vas Surg.2009;49:1403-08 94 (24.6%) 68(17.8%) 192(50.3%) 28(7.4%) DuBose,JTraumaAcute Care Surg 2015;78:360-369
Treatment BTAI ASST II 2015 76.4% TAVER vs 23.5% Open vs 32.2% Non Op DuBose,JTraumaAcute Care Surg 2015;78:360-369
Early Technology Challenging
Improving Technology Conformational Endograft ASSTS I 2008 vs ASSTS II 2015 Endo Complication 18.4% (13.6 e-leak) vs 5.5% DuBose,JTraumaAcute Care Surg 2015;78:360-369
Predictors Aortic Mortality BTAI Pts Variable Odds Ratio p ISS 1.07 0.015 Lesion Grade 17.18 0.0001 TEVAR 0.21 0.033 Chest AIS Score 6.41 0.023 DuBose,JTraumaAcute Care Surg 2015;78:360-369
TEVAR vs. OPEN REPAIR 90 80 70 60 50 40 30 20 10 0 Time to Treatment, Open vs. TEVAR Mean Time to Rx Open 34hr TAVER 74 hr! Open Cases TAVR Cases Column1 Admission 6 Hours 24 Hours 48 Hours DuBose,JTraumaAcute Care Surg 2015;78:360-369
LEE,WA J Vasc Surg 2011;53:187-92
Non-operative Management of Blunt Traumatic Aortic Injury (BTAI) Joseph Rabin MD, Joe DuBose MD, Clint W. Sliker MD, James V. O Connor MD, Thomas M. Scalea MD, and Bartley P. Griffith MD. Disclosures: None
Excluded: in extremis low grade lesions repair < 48 hrs non-aortic death < 48h 284 BTAI UMD patients 2000-2013 49 Stable + high grade lesion 18 Rupture: Contrast extravasation Surgery or autopsy 31 Stable: No repair within 48 hrs HarrisDG,TaylorB, J Vasc Surg 2015;61:332-8
Model Construction Factors dichotomized for univariate analysis Strongest factor from each data group included for multivariate analysis Factors weighted according to β coefficient A priori goal of 100% sensitivity HarrisDG, J Vasc Surg 2015;61:332-8
12 10 8 6 4 2 0 Factor mm Lactate > 4 mm Diameter ratio > 1.4 DTA hematoma > 10 mm Lactate β coefficient Multivariate P Odds Ratio Weig ht 0.29 0.002 1.3 (1.1 1.6) 0.31 0.003 1.4 (1.1 1.7) 0.53 <0.001 1.7 (1.4 2.1) Model Components 2 2 3
Points 7 Sensitivity: 100% Specificity: 84% Accuracy: 90% AUROC.97 6 5 4 3 2 1 0 Rupture, n=18 Stable, n=31 Mean: 6 ± 1 2 ± 2 P < 0.0001
Operational Use High risk for aortic rupture when any 2 are present: Lactate > 4 mm Mediastinal hematoma > 10 mm Lesion: normal aortic ratio > 1.4 mm HarrisDG, J Vasc Surg 2015;61:332-8
What Happens to the 20 yo trauma patient with a 20mm device who is going to live 50 years? What is the durability of the device? Now 15 year data. Discussion AATS, JTCVS 2010;140:598-605 Anthony Caffarelli AATS
Standford Led TAVER but... CT indicative of Stable Aorta but, 70% Small Pseudo Aneurysms <3cm Caffarelli: The Journal of Thoracic and Cardiovascular Surgery, Volume 140, 2010, 598-605
Bart s Recommendations Grade I & II Watch with Med Rx Grade III <4 cms can watch if needed but prefer treating Model Seems Reasonable Guide 2 of 3 Lactate>4, Hematoma>10, Lesion/Aorta>1.4
Delayed Repair May Reduce TBI EARLY REPAIR DELAYED REPAIR # Patients 29 24 P Value Days to Repair 0.3 3.6 0.001 GCS & BAIS 7 & 4 9 & 4 ns Progressive TBI 34% 0 % 0.001 Mortality 7 (24 %) 4 (17%) ns Rabin, AnnThoracSurg 2014;98:46-52
Model Performance 1.0 0.8 Sensitivity 0.6 0.4 AUROC: 0.98 (0.94 1.0) 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 1 - Specificity
Outcome Outcomes Rupture, n = 18 Stable, n = 31 Inpatient mortality 89% 23% Aortic mortality 83% 0% CT to decompensation, med (IQR) 64hr (44 124) n/a
Can a Aortic Injury Score Guide Early vs Delayed Treatment of BTAI Donald G. Harris, Joseph Rabin, Robert S. Crawford
J Vasc Surg 2011;53:187-92
J Vasc Surg 2011;53:187-92
Admission Lactate Rupture Stable 12 10 8 mm 6 4 2 0
Admission Characteristic Derivation Rupture, Groups n = 18 Stable, n = 31 Age, yrs 48 ± 19 45 ± 22 0.63 Male, n (%) 14 (78) 21 (68) 0.53 Mean Art. Pressure, mmhg 84 ± 27 83 ± 19 0.93 Heart Rate, bpm 108 ± 34 111 ± 34 0.81 Glasgow coma scale 9 ± 5 11 ± 5 0.42 Non-chest injury severity score 26 ± 12 30 ± 13 0.26 Revised trauma score 5.67 ± 2.30 6.22 ± 1.97 0.39 Hemoglobin, g/dl 12 ± 2 12 ± 2 0.94 Lactate, mm 7 ± 3 4 ± 2 0.007 P
Diameter Ratio
Periaortic Hematoma
High Grade Aortic Injury
High Grade Aortic Injury
Traumatic Aortic Injury Second most common cause of death due to blunt trauma Annual incidence in U.S. - 7,500-8,000 1,000-1,500 arrive to hospital alive Fabian TC, Richardson JD, Croce MA, Smith JS, Jr., Rodman G, Jr., Kearney PA, Flynn W, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma. 42: 374-80; discussion 380-3, 1997.
Methods Retrospective study (7/2005-7/2007) 26 consecutive patients with TAI treated with aortic endograft Comparison Group 26 consecutive patients treated with open surgery (7/03-12/05) Left heart bypass (heparinized circuit)
Aortic Injury Morphology and Location Non-operative Survivors INJURY LOCATION INJURY TYPE Arch Isthmus Descending Intraluminal thrombus/intimal injury 2 4 Mural hematoma 1 1 Pseudoaneurysm <½ aortic circumference Pseudoaneurysm >½ aortic circumference 1 15 2 1 Caffarelli et al. J Thorac Cardiovasc Surg 2010 40:598-605
Evolution in BTAI AATS 1 (1998) vs. AATS 2 (2008) Diagnosis by CT: 8.3 vs. 84.4% Endographic Repair now: 65% Reduced Mortality : 22 vs. 13% Procedural Paraplegia: 8.7 vs. 1.6 % Time to Rx: 16 vs. 54 Hrs.
Lactate: 2.6 mm Ratio: 1.7 Hematoma: 0 mm
Lactate: 4.4 mm Ratio: 1.6 Hematoma: 16 mm
Lactate: 4.4 mm Ratio: 1.6 Hematoma: 16 mm
Clinical Assessment Test 9 blinded vascular surgeon reviewers Vitals, labs & representative CT slices Performance compared to model
Model vs Clinical Assessment Clinical Test Risk Model P Sensitivity 0.7 ± 0.1 1.0 < 0.05 Specificity 0.6 ± 0.1 0.8 < 0.05 Accuracy 0.6 ± 0.1 0.9 < 0.01
Discussion High grade BTAI Aortic risk score Negative Positive Delayed repair Immediate repair
Summary Risk score reliably identifies high-risk BTAI Improves patient selection Opportunity to optimize management of patients with high-grade aortic lesions
# Patients Dying ISTHUMUS RUPTURE 3 3 3 3 3 2 2 1 1 1 <1H 1<6 H 6-<24H 1-2D 3-4D 5-7D 8-14D 15D-3M 4-12M 2-3Y
% TREATED 160 140 120 100 80 60 40 20 0 Mean: 34Hr Mean:75Hr. OPEN vs TEVAR Admission 6 Hours 24 Hours 48 Hours HOURS to TREATMENT TEVAR Open Non-Op: 122pts(30%) Grade I & II 91 pts. vs TEVAR 61pts. Open: 61pts(16%) higher ISS, HemotomaComprssion, RBC tx ------------------------------------ ----------------------------------------------------------------------TEVAR: 198 pts(54%)
Can an Aortic Injury Score Guide Early vs Delayed Treatment of BTAI