Development and Validation of a Risk Prediction Tool for In-hospital Mortality After Thoracic Endovascular Repair in Patients with Blunt Thoracic Aortic Injury Using the Aortic Trauma Foundation Registry.

BACKGROUND: The objective of our present effort was to use an international blunt thoracic aortic injury (BTAI) registry to create a prediction model identifying important preoperative and intraoperative factors associated with postoperative mortality, and to develop and validate a simple risk prediction tool that could assist with patient selection and risk stratification in this patient population. METHODS: For the purpose of the present study, all patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI and registered in the Aortic Trauma Foundation (ATF) database from January 2016 as of June 2022 were identified. Patients undergoing medical management or open repair were excluded. The primary outcome was binary in-hospital all-cause mortality. Two predictive models were generated: a preoperative model (i.e. only including variables before TEVAR or intention-to-treat) and a full model (i.e. also including variables after TEVAR or per-protocol). RESULTS: Out of a total of 944 cases included in the ATF registry until June 2022, 448 underwent TEVAR and were included in the study population. TEVAR for BTAI was associated with an 8.5% in-hospital all-cause mortality in the ATF dataset. These study subjects were subsequently divided using 3:1 random sampling in a derivation cohort (336; 75.0%) and a validation cohort (112; 25.0%). The median age was 38 years, and the majority of patients were male (350; 78%). A total of 38 variables were included in the final analysis. Of these, 17 variables were considered in the preoperative model, 9 variables were integrated in the full model, and 12 variables were excluded owing to either extremely low variance or strong correlation with other variables. The calibration graphs showed how both models from the ATF dataset tended to underestimate risk, mainly in intermediate-risk cases. The discriminative capacity was moderate in all models; the best performing model was the full model from the ATF dataset, as evident from both the Receiver Operating Characteristic curve (Area Under the Curve 0.84; 95% CI 0.74-0.91) and from the density graph. CONCLUSIONS: In this study, we developed and validated a contemporary risk prediction model, which incorporates several preoperative and postoperative variables and is strongly predictive of early mortality. While this model can reasonably predict in-hospital all-cause mortality, thereby assisting physicians with risk-stratification as well as inform patients and their caregivers, its intrinsic limitations must be taken into account and it should only be considered an adjunctive tool that may complement clinical judgment and shared decision-making.

Cardiac and Aortic Modifications After Endovascular Repair for Blunt Thoracic Aortic Injury: A Systematic Review.

OBJECTIVE: Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however, it has also been demonstrated to alter cardiovascular haemodynamics. The aim of this systematic review was to describe the cardiovascular modifications after thoracic endovascular aortic repair (TEVAR) for BTAI. DATA SOURCES: PubMed (MEDLINE), Scopus, and Web of Science were systematically searched for eligible studies reporting on modifications in aortic stiffness, blood pressure, cardiac mass, and aortic size. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. RESULTS: A total of 12 studies reporting on 265 patients were included. Severe heterogeneity existed among the included studies with regard to demographics, BTAI grade, endograft specifications, reported outcomes, and the method of evaluation. Regarding aortic stiffness, two studies found a significant increase in pulse wave velocity (PWV) in patients after TEVAR compared with a control group, while one did not find a significant increase in PWV and augmentation index after > 3 years of follow up. Five studies reported an increase in the incidence of post-TEVAR hypertension up to 55% (range 34.8% - 55.0%) vs. baseline. One study found a statistically significant increase in left ventricular mass and left ventricular mass index during follow up. Nine studies report data regarding aortic dilatation or remodelling after TEVAR. One found a 2.4 fold faster growth rate in ascending aortic diameter vs. controls, while other studies described significant changes in aortic size at different locations along the aorta and endograft after TEVAR. CONCLUSION: This systematic review highlights adverse cardiac and aortic modifications after TEVAR for BTAI. The results stress the need for lifelong surveillance in these patients and the necessity of developing a more compliant endograft to prevent cardiovascular complications in the long term.

Concurrent Thoracic Endovascular Aortic Repair and Liver Transplant: Multidisciplinary Management of Multiple Posttraumatic Lesions.

Association of thoracic and abdominal injuries in patients with major trauma is common. Under emergency conditions, it is often difficult to promptly perform a certain diagnosis and identify treatment priorities of life-threatening lesions. We present the case of a young man with combined thoracic and abdominal injuries after a motorcycle accident. Primary evaluation through echography and X-ray showed fluid within the hepatorenal recess and an enlarged mediastinum. Volume load, blood transfusions, and vasoactive agents were initiated to sustain circulation. Despite hemodynamic instability, we decided to perform computed tomographic angiography (CTA) scan that revealed a high-grade traumatic aortic pseudoaneurysm, multiple and severe areas of liver contusion, and a small amount of hemoperitoneum, without active bleeding spots. The patient was successfully submitted to thoracic endovascular aortic repair (TEVAR). Immediately after the end of the successful TEVAR, signs of massive abdominal bleeding revealed. Immediate explorative laparotomy was performed showing massive hepatic hemorrhage. After liver packing and Pringle's maneuver, control of bleeding was lastly obtained with hemostatic devices and selective cross-clamping of the right hepatic artery. The patient was then transferred to intensive care unit where, despite absence of further hemorrhage, hemodynamic instability, anuria, severe lactic acidosis together with liver necrosis indices appeared. A new CTA demonstrated massive parenchymal disruption within the right lobe of the liver and multiple hematomas in the left lobe. Considering the high-grade lesions of the hepatic vascular tree and liver failure, patient was listed for emergency liver transplantation (LT). LT occurred few hours later, and patient's clinical conditions rapidly improved even if the subsequent clinical course was characterized by a severe fungal infection because of immunosuppression. Evaluation of life-threatening lesions and treatment priorities, availability of different excellence skills, and multidisciplinary collaboration have a key role to achieve clinical success in such severe cases.

Operative Treatment and Clinical Outcomes in Peripheral Vascular Trauma: The Combined Experience of Two Centers in the Endovascular Era.

BACKGROUND: Arterial traumas of the extremities are quite rare in civilian records; nevertheless, patients with trauma of limbs are admitted daily in emergency departments worldwide. The up-to-date information about epidemiology and treatment (open vs. endovascular surgery) comes from war records and it is not always easy getting data on mortality and morbidity in these patients. The aim of this study is to analyze the approach (open or endovascular) and the outcome of patients with vascular trauma of upper limbs (from the subclavian artery) and/or lower limbs (distal to the inguinal ligament), in the greater Milan area. METHODS: A retrospective analysis was conducted on data recorded by the emergency departments of two hospitals of the greater Milan between 2009 and 2017. We collected all patients with arterial injuries of the limbs in terms of demography, injury patterns, clinical status at admission, therapy (open or endovascular approach), and outcomes in terms of limb salvage and survival. RESULTS: We studied 52 patients with vascular trauma of extremities. The main mechanism of trauma was road accident (48.1%), followed by criminal acts (32.7%), self-endangering behavior (13.5%), work (3.8%), and sport accidents (1.9%). Associated lesions (orthopedic, neurological, and/or venous lesions of the limbs) were present in 39 patients (75%). All patients underwent emergency surgery, forty-six patients (88.5%) by open repair (polytetrafluoroethylene or greater saphenous vein bypass grafts, arterial suture or ligation), whereas endovascular approach was used only in 6 patients (11.5%), all treated with embolization. The overall postoperative mortality rate was 5.7% (3 patients). Among survivors, we report 5 major amputations of the lower limbs, 3 of them after bypass graft infection, and 2 after graft failure. The rate of limb salvage was 90.4%. CONCLUSIONS: Isolated arterial trauma of the extremities are rare, usually they occur in the setting of multiple trauma patients. Despite progresses in surgical techniques, there are still controversies in diagnosis and treatment of these patients. We treated most cases with open surgery (n = 46), choosing endovascular approach (embolization performed mainly by interventional radiologists) in difficult anatomic districts. We believe that, during decision-making of the surgical strategy, it is important to consider the anatomical site of lesions and the general condition of the patients. Moreover, in case of multiple trauma, we suggest a multidisciplinary approach to provide the best medical care to the victims.

Caveat for Vascular Surgeons: Lesson Learned from Acute Onset of a Rare Aortic Paraganglioma in a Young Boy.

BACKGROUND: Paragangliomas (PGs) are rare neuroendocrine tumors arising from the extra-adrenal autonomic paraganglia that are tiny organs formed by bundles of neuroendocrine cells derived from the embryonic neural crest and capable of catecholamines secretion. Diagnosis and treatment of aortic PGs could be a challenging issue when they present as an emergency setup (sudden abdominal pain and radiological images resembling a vascular emergency). CASE REPORT: We present a rare case of a 16-year-old man with a symptomatic and bleeding left para-aortic mass, treated in emergency with embolization, before a staged videolaparoscopic resection. Histology of the mass showed the presence of a large aortic PG. CONCLUSIONS: In case of active bleeding, in emergency, vascular consultants are always involved. Sometimes, circumstances are very atypical; therefore, it is essential to keep in mind rare pathologies. In such settings, multidisciplinary approach is primary to obtain a prompt diagnosis and appropriate treatment.

Concomitant Renal Artery and Aortic Aneurysm: Is Endovascular Surgery the Correct Approach?

Our case illustrates the concomitant presence of a giant aneurysm of the left renal artery at the ostium and an abdominal aortic aneurysm, in presence of a complex aortic anatomy. Type of approach and timing of the treatment is still not well established for the rare coexistence of these 2 pathologies. In case of surgical high-risk patients, endovascular therapy is considered now the best choice to exclude arterial and aortic aneurysms although there are chances to do further interventions in the follow-up. For this reason, we simultaneously treated both the aneurysms through an embolization with plugs and coils of renal aneurysm and endovascular exclusion of aortic aneurysm; in the follow-up, renal function of the patient worsened until hemodialysis and we saw the reperfusion of renal aneurysm and the onset of endoleak I type A from above the aortic and renal aneurysm and B from iliac legs of the previous endograft. We performed a parallel graft technique on visceral vessels to exclude the refilling of both aneurysms and preserve visceral vascularization. Follow-up at 12 months showed the complete exclusion of the aneurysms and the patency of stents in celiac trunk and superior mesenteric artery.

Cardiovascular Remodeling after Endovascular Treatment for Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) currently represents the gold standard of treatment for thoracic aortic injury (TAI). Nevertheless, there is an ongoing debate surrounding its safety and subsequent cardiovascular effects. Our aim is to assess heart and vascular structure and function remodeling after TEVAR in TAI young patients. METHODS: We evaluated 20 patients (18 men, age 41 ± 14 years, 11 treated with Gore CTAG, 9 with Medtronic Valiant) with office and 24-hr blood pressure (BP) with specific vascular stiffness analysis (Mobil-O-Graph), aortic diameters (computed tomography scan) and left ventricular mass index (LVMI echocardiogram). Evaluation was done after a median time of 5.0 ± 3.5 years from the trauma. RESULTS: After TAI 12 patients (55%) developed hypertension. When patients were divided according to treating time, those treated for more than 3 years show higher LVMI, PWV, and ascending aorta dilatation. CONCLUSIONS: Our study shows that TEVAR for TAI is associated with heart and vascular remodeling. The presence of TEVAR modifies aortic functional properties and could induce an increase in BP that can promote aortic and cardiac damage, even in young patients.

Successful Fat Grafting in a Patient With Thromboangiitis Obliterans.

Thromboangiitis obliterans, or Buerger disease, is a rare nonatherosclerotic segmental inflammatory vasculitis that generally affects young tobacco smokers. Although no surgical treatment is available, the most effective way to halt the disease's progress is smoking cessation. In this case report, a 29-year-old smoker showed up to emergency department with gangrene of his fifth left toe and extensive plantar ulceration. After investigative angiography, he was diagnosed with Buerger disease. On November 2017, he underwent fifth left toe amputation and hyperbaric therapy. Five months after amputation, the patient was rehospitalized because of surgical wound dehiscence, wide ulceration, and pain. He was treated with lipofilling using the Coleman technique. Two weeks after the fat grafting procedure, the patient suspended pain control medication, and after 2 months, the surgical wound was almost healed. Fat grafting (lipofilling) is mostly used in plastic surgery; it offers regenerative effects, with minimal discomfort for the patient. This case report demonstrates a successful alternative use of lipofilling for this unique condition and opens up new options for use of this technique in other fields.

Multiple Idiopathic Aneurysms in a 6-Year-Old Boy.

We report the rare case of a young boy affected by idiopathic multiple aneurysms at different arterial locations who was treated at our institution with different surgical and endovascular techniques.

Acute venous problems: Integrating medical, surgical, and interventional treatments.

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

A rare case of paradoxical pulmonary embolism in spontaneous aortocaval fistula.

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in less than 1% of all AAAs. Paradoxical embolism can rarely be associated with ACF, pulmonary embolism may originate from dislodgment of thrombotic material from the AAA in the inferior vena cava (IVC) through the ACF. We report a case of a patient admitted to the emergency department with abdominal pain and shortness of breath who immediately underwent thoraco-abdominal CT. Imaging allowed a prompt pre-operative diagnosis of an ACF between an AAA and the IVC, also identifying CT signs of right heart overload and the presence of a paradoxical pulmonary embolism.

Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. EVIDENCE ACQUISITION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. EVIDENCE SYNTHESIS: Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. CONCLUSIONS: TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.