The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury

A Western Trauma Association Multicenter Study

Steven R. Shackford, Casey E. Dunne, Riyad Karmy-Jones, William Long, Desarom Teso, Martin Schreiber, Justin Watson, Cheri Watson, Robert C. McIntyre, Lisa Ferrigno, Mark L. Shapiro, Kevin Southerland, Julie A. Dunn, Paul Reckard, Thomas M. Scalea, Megan Brenner, William A. Teeter

    Research output: Contribution to journalArticle

    10 Citations (Scopus)

    Abstract

    BACKGROUND: The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. METHODS: Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between 1/1/2006 and 6/30/2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. RESULTS: We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). TEVAR and open repair groups had similar ISS, chest AIS, TRISS and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}: 19-51]; TEVAR: 46 [IQR: 28-60], p<0.007), zone of aortic injury (p<0.001), and grade of aortic injury (open: 6 [IQR: 4-6]; TEVAR: 2 [IQR: 2-4], p<0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%, p=0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%. CONCLUSIONS: The mortality of BTAI continues to decrease. TEVAR, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in CT imaging in follow-up of TEVAR is warranted. LEVEL OF EVIDENCE: Level III, therapeutic/care management

    Original languageEnglish (US)
    JournalJournal of Trauma and Acute Care Surgery
    DOIs
    StateAccepted/In press - May 22 2017

    Fingerprint

    Thoracic Injuries
    Nonpenetrating Wounds
    Multicenter Studies
    Thorax
    Wounds and Injuries
    Risk Adjustment
    Trauma Centers
    Hospital Mortality
    Stents
    Comorbidity
    Therapeutics

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury : A Western Trauma Association Multicenter Study. / Shackford, Steven R.; Dunne, Casey E.; Karmy-Jones, Riyad; Long, William; Teso, Desarom; Schreiber, Martin; Watson, Justin; Watson, Cheri; McIntyre, Robert C.; Ferrigno, Lisa; Shapiro, Mark L.; Southerland, Kevin; Dunn, Julie A.; Reckard, Paul; Scalea, Thomas M.; Brenner, Megan; Teeter, William A.

    In: Journal of Trauma and Acute Care Surgery, 22.05.2017.

    Research output: Contribution to journalArticle

    Shackford, SR, Dunne, CE, Karmy-Jones, R, Long, W, Teso, D, Schreiber, M, Watson, J, Watson, C, McIntyre, RC, Ferrigno, L, Shapiro, ML, Southerland, K, Dunn, JA, Reckard, P, Scalea, TM, Brenner, M & Teeter, WA 2017, 'The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury: A Western Trauma Association Multicenter Study', Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000001555
    Shackford, Steven R. ; Dunne, Casey E. ; Karmy-Jones, Riyad ; Long, William ; Teso, Desarom ; Schreiber, Martin ; Watson, Justin ; Watson, Cheri ; McIntyre, Robert C. ; Ferrigno, Lisa ; Shapiro, Mark L. ; Southerland, Kevin ; Dunn, Julie A. ; Reckard, Paul ; Scalea, Thomas M. ; Brenner, Megan ; Teeter, William A. / The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury : A Western Trauma Association Multicenter Study. In: Journal of Trauma and Acute Care Surgery. 2017.
    @article{8ed3b00663aa48abb067b467ab079e01,
    title = "The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury: A Western Trauma Association Multicenter Study",
    abstract = "BACKGROUND: The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. METHODS: Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between 1/1/2006 and 6/30/2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. RESULTS: We studied 316 patients with BTAI; 57 (18.0{\%}) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0{\%}), open in 28 (10.8{\%}), hybrid in 4 (1.5{\%}), and nonoperative in 51 (19.7{\%}). TEVAR and open repair groups had similar ISS, chest AIS, TRISS and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}: 19-51]; TEVAR: 46 [IQR: 28-60], p<0.007), zone of aortic injury (p<0.001), and grade of aortic injury (open: 6 [IQR: 4-6]; TEVAR: 2 [IQR: 2-4], p<0.001). The overall in-hospital mortality was 6.6{\%} (TEVAR: 5.7{\%}, open: 10.7{\%}, nonoperative: 3.9{\%}, p=0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6{\%}. CONCLUSIONS: The mortality of BTAI continues to decrease. TEVAR, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in CT imaging in follow-up of TEVAR is warranted. LEVEL OF EVIDENCE: Level III, therapeutic/care management",
    author = "Shackford, {Steven R.} and Dunne, {Casey E.} and Riyad Karmy-Jones and William Long and Desarom Teso and Martin Schreiber and Justin Watson and Cheri Watson and McIntyre, {Robert C.} and Lisa Ferrigno and Shapiro, {Mark L.} and Kevin Southerland and Dunn, {Julie A.} and Paul Reckard and Scalea, {Thomas M.} and Megan Brenner and Teeter, {William A.}",
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    T1 - The Evolution of Care Improves Outcome in Blunt Thoracic Aortic Injury

    T2 - A Western Trauma Association Multicenter Study

    AU - Shackford, Steven R.

    AU - Dunne, Casey E.

    AU - Karmy-Jones, Riyad

    AU - Long, William

    AU - Teso, Desarom

    AU - Schreiber, Martin

    AU - Watson, Justin

    AU - Watson, Cheri

    AU - McIntyre, Robert C.

    AU - Ferrigno, Lisa

    AU - Shapiro, Mark L.

    AU - Southerland, Kevin

    AU - Dunn, Julie A.

    AU - Reckard, Paul

    AU - Scalea, Thomas M.

    AU - Brenner, Megan

    AU - Teeter, William A.

    PY - 2017/5/22

    Y1 - 2017/5/22

    N2 - BACKGROUND: The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. METHODS: Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between 1/1/2006 and 6/30/2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. RESULTS: We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). TEVAR and open repair groups had similar ISS, chest AIS, TRISS and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}: 19-51]; TEVAR: 46 [IQR: 28-60], p<0.007), zone of aortic injury (p<0.001), and grade of aortic injury (open: 6 [IQR: 4-6]; TEVAR: 2 [IQR: 2-4], p<0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%, p=0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%. CONCLUSIONS: The mortality of BTAI continues to decrease. TEVAR, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in CT imaging in follow-up of TEVAR is warranted. LEVEL OF EVIDENCE: Level III, therapeutic/care management

    AB - BACKGROUND: The management of blunt thoracic aortic injury (BTAI) has evolved radically in the last decade with changes in the processes of care and the introduction of thoracic endovascular repair (TEVAR). These changes have wrought improved outcome, but the direct effect of TEVAR on outcome remains in question as previous studies have lacked vigorous risk adjustment and long-term follow-up. To address these knowledge gaps, we compared the outcomes of TEVAR, open surgical repair, and nonoperative management for BTAI. METHODS: Eight verified trauma centers recruited from the Western Trauma Association Multicenter Study Group retrospectively studied all patients with BTAI admitted between 1/1/2006 and 6/30/2016. Data included demographics, comorbidities, admitting physiology, injury severity, in-hospital care, and outcome. RESULTS: We studied 316 patients with BTAI; 57 (18.0%) were in extremis and died before treatment. Of the 259 treated surgically, TEVAR was performed in 176 (68.0%), open in 28 (10.8%), hybrid in 4 (1.5%), and nonoperative in 51 (19.7%). TEVAR and open repair groups had similar ISS, chest AIS, TRISS and probability of survival, but differed in median age (open: 28 [interquartile range {IQR}: 19-51]; TEVAR: 46 [IQR: 28-60], p<0.007), zone of aortic injury (p<0.001), and grade of aortic injury (open: 6 [IQR: 4-6]; TEVAR: 2 [IQR: 2-4], p<0.001). The overall in-hospital mortality was 6.6% (TEVAR: 5.7%, open: 10.7%, nonoperative: 3.9%, p=0.535). Of the 240 patients who survived to discharge, two died (one at 9 months and one at 8 years); both were managed with TEVAR, but the deaths were unrelated to the aortic procedure. Stent graft surveillance computed tomography scans were not obtained in 37.6%. CONCLUSIONS: The mortality of BTAI continues to decrease. TEVAR, when anatomically suitable, should be the treatment of choice. Open repair remains necessary for more proximal injuries. Process improvement in CT imaging in follow-up of TEVAR is warranted. LEVEL OF EVIDENCE: Level III, therapeutic/care management

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