Surgeon volume and outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS: We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS: We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS: In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.

The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury.

OBJECTIVE: There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. METHODS: This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. RESULTS: A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. CONCLUSIONS: BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.

Early survival benefit of a low-profile endograft in blunt traumatic aortic injury.

OBJECTIVE: The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. METHODS: A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. RESULTS: The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. CONCLUSIONS: RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis.

INTRODUCTION: This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries. METHODS: This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival. RESULTS: Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001). CONCLUSIONS: SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis.

INTRODUCTION: We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries. METHODS: Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality. RESULTS: The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01). CONCLUSIONS: VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.

Shifting Perspectives: Equal Blunt Cerebrovascular Risk in Low-Versus High-Energy Cervical Fracture.

INTRODUCTION: Clinical implications of screening for blunt cerebrovascular injury (BCVI) after low-energy mechanisms of injury (LEMI) remain unclear. We assessed BCVI incidence and outcomes in LEMI versus high-energy mechanisms of injury (HEMI) patients. METHODS: In this retrospective cohort study, blunt trauma adults admitted between July 2015 and June 2021 with cervical spine fractures, excluding single spinous process, osteophyte, and chronic fractures were included. Demographics, comorbidities, injuries, screening and treatment data, iatrogenic complications, and mortality were collected. Our primary end point was to compare BCVI rates between LEMI and HEMI patients. RESULTS: Eight hundred sixty patients (78%) were screened for BCVI; 120 were positive for BCVI. LEMI and HEMI groups presented similar BCVI rates (12.6% versus 14.4%; P = 0.640). Compared to HEMI patients (n = 95), LEMI patients (n = 25) were significantly older (79 ± 14.9 versus 54.3 ± 17.4, P < 0.001), more likely to be on anticoagulants before admission (64% versus 23.2%, P < 0.001), and less severely injured (LEMI injury severity score 10.9 ± 6.6 versus HEMI injury severity score 18.7 ± 11.4, P = 0.001). All but one LEMI and 90.5% of the HEMI patients had vertebral artery injuries with no significant difference in BCVI grades. One HEMI patient developed acute kidney injury because of BCVI screening. Eleven HEMI patients developed BCVI-related stroke with two related mortalities. One LEMI patient died of a BCVI-related stroke. CONCLUSIONS: BCVI rates were similar between HEMI and LEMI groups when screening based on cervical spine fractures. The LEMI group exhibited no screening or treatment complications, suggesting that benefits may outweigh the risks of screening and potential bleeding complications from treatment.

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries.

INTRODUCTION: Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. METHODS: In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed. RESULTS: Over 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038). CONCLUSIONS: Difficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia.

INTRODUCTION: When an injured patient arrives in the Emergency Department (ED), timely and appropriate care is crucial. Shock Index Pediatric Age-Adjusted (SIPA) has been shown to accurately identify pediatric patients in need of emergency interventions. However, no study has evaluated SIPA against age-adjusted tachycardia (AT). This study aims to compare SIPA with AT in predicting outcomes such as mortality, severe injury, and the need for emergent intervention in pediatric trauma patients. MATERIAL AND METHODS: This is a retrospective cross-sectional analysis of patient data abstracted from the Trauma Quality Improvement Program Participant Use Files (TQIP PUFs) for years 2013-2020. Patients aged 4-16 with blunt mechanism of injury and injury severity score (ISS) > 15 were included. 36,517 children met this criteria. Sensitivity, specificity, overtriage, and undertriage rates were calculated to compare the effectiveness of AT and elevated SIPA as predictors of severe injuries and need for emergent intervention. Emergent interventions included craniotomy, endotracheal intubation, thoracotomy, laparotomy, or chest tube placement within 24 h of arrival. RESULTS: AT classified 59% of patients as "high risk," while elevated SIPA identified 26%. Compared to AT patients, a greater proportion of patients with elevated SIPA required a blood transfusion within 24 h (22% vs. 12%, respectively; p < 0.001). In-hospital mortality was higher for the elevated SIPA group than AT (10% vs. 5%, respectively; p < 0.001) as well as the need for emergent operative interventions (43% vs. 32% respectively; p < 0.001). Grade 3 or higher liver/spleen lacerations requiring blood transfusion were also more common among elevated SIPA patients than AT patients (8% vs. 4%, respectively; p < 0.001). AT demonstrated greater sensitivity but lower specificity compared to SIPA across all outcomes. AT showed improved overtriage and undertriage rates compared to SIPA, but this is attributed to identifying a large proportion of the sample as "high risk." CONCLUSIONS: AT outperforms SIPA in sensitivity for mortality, injury severity and emergent interventions in pediatric trauma patients while the specificity of SIPA is high across these outcomes.

Current aspects in the management of esophageal trauma: a systematic review and proportional meta-analysis.

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13-25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49-0.89, P = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32-73%), with 68% of patients having associated injuries (95% CI 43-94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1-6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14-8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases.

Prognosis and assessment of the predictive value of severity scores in paediatric abdominal trauma: A French national cohort study.

BACKGROUND: Paediatric closed abdominal trauma is common, however, its severity and influence on survival are difficult to determine. No prognostic score integrating abdominal involvement exists to date in paediatrics. OBJECTIVES: To evaluate the severity and short-term and medium-term prognosis of closed abdominal trauma in children, and the performance of severity scores in predicting mortality. DESIGN: Retrospective, cohort, observational study. SETTING AND PARTICIPANTS: Patients aged 0 to 18 years presenting at the trauma room of a French paediatric Level I Trauma Centre over the period 2015 to 2019 with an isolated closed abdominal trauma or as part of a polytrauma. MAIN OUTCOMES: Primary outcome was the six months mortality. Secondary outcomes were related complications and therapeutic interventions, and performance for predicting mortality of the scores listed. Paediatric Trauma Score (PTS), Revised Trauma Score (RTS), Shock Index Paediatric Age-adjusted (SIPA) score, Reverse shock index multiplied by Glasgow Coma Scale score (rSIG), Base Deficit, International Normalised Ratio, and Glasgow Coma Scale (BIG), Injury Severity Score (ISS) and Trauma Score and the Injury Severity (TRISS) score. DATA COLLECTION: Data collected include clinical, biological and CT scan data at admission, first 24 h management and prognosis. The PTS, RTS, SIPA, rSIG, BIG and ISS scores were calculated and mortality was predicted according to BIG score and TRISS methodology. RESULTS: Of 1145 patients, 149 met the inclusion criteria and 12 (8.1%) died. Of the 12 deceased patients, 11 (91.7%) presented with severe head injury, 11 (91.7%) had blood products transfusion and 7 received tranexamic acid. ROC curves analysis concluded that PTS, RTS, rSIG and BIG scores accurately predict mortality in paediatric closed abdominal trauma with AUCs at least 0.92. The BIG score offered the best predictive performance for predicting mortality at a threshold of 24.8 [sensitivity 90%, specificity 92%, negative-predictive value (NPV) 99%, area under the curve (AUC) 0.93]. CONCLUSION: PEVALPED is the first French study to evaluate the prognosis of paediatric closed abdominal trauma. The use of PTS, rSIG and BIG scores are relevant from the acute phase and the pathophysiological interest and accuracy of the BIG score make it a powerful tool for predicting mortality of closed abdominal trauma in children.

Mortality of traumatic chest injury and its predictors across sub-saharan Africa: systematic review and meta-analysis, 2024.

INTRODUCTION: Globally, chest trauma remain as a prominent contributor to both morbidity and mortality. Notably, patients experiencing blunt chest trauma exhibit a higher mortality rate (11.65%) compared to those with penetrating chest trauma (5.63%). AIM: This systematic review and meta-analysis aimed to assess the mortality rate and its determinants in cases of traumatic chest injuries. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the data synthesis process. Multiple advanced search methods, encompassing databases such as PubMed, Africa Index Medicus, Scopus, Embase, Science Direct, HINARI, and Google Scholar, were employed. The elimination of duplicate studies occurred using EndNote version X9. Quality assessment utilized the Newcastle-Ottawa Scale, and data extraction adhered to the Joanna Briggs Institute (JBI) format. Evaluation of publication bias was conducted via Egger's regression test and funnel plot, with additional sensitivity analysis. All studies included in this meta-analysis were observational, ultimately addressing the query, what is the pooled mortality rate of traumatic chest injury and its predictors in sub-Saharan Africa? RESULTS: Among the 845 identified original articles, 21 published original studies were included in the pooled mortality analysis for patients with chest trauma. The determined mortality rate was nine (95% CI: 6.35-11.65). Predictors contributing to mortality included age over 50 (AOR 3.5; 95% CI: 1.19-10.35), a time interval of 2-6 h between injury and admission (AOR 3.9; 95% CI: 2.04-7.51), injuries associated with the head and neck (AOR 6.28; 95% CI: 3.00-13.15), spinal injuries (AOR 7.86; 95% CI: 3.02-19.51), comorbidities (AOR 5.24; 95% CI: 2.93-9.40), any associated injuries (AOR 7.9; 95% CI: 3.12-18.45), cardiac injuries (AOR 5.02; 95% CI: 2.62-9.68), the need for ICU care (AOR 13.7; 95% CI: 9.59-19.66), and an Injury Severity Score (AOR 3.5; 95% CI: 10.6-11.60). CONCLUSION: The aggregated mortality rate for traumatic chest injuries tends to be higher in sub-Saharan Africa. Factors such as age over 50 years, delayed admission (2-6 h), injuries associated with the head, neck, or spine, comorbidities, associated injuries, cardiac injuries, ICU admission, and increased Injury Severity Score were identified as positive predictors. Targeted intervention areas encompass the health sector, infrastructure, municipality, transportation zones, and the broader community.

Nephrectomy Is Not Associated with Increased Risk of Mortality or Acute Kidney Injury after High-Grade Renal Trauma: A Propensity Score Analysis of the Trauma Quality Improvement Program (TQIP).

PURPOSE: Patients with high-grade renal trauma (HGRT) undergoing nephrectomy may be at higher risk for mortality compared to those treated conservatively. However, no study has controlled for degree of hemorrhage as a measure of shock. We hypothesized that after controlling for blood transfusions and other factors, nephrectomy after HGRT would be associated with increased mortality and acute kidney injury (AKI). MATERIALS AND METHODS: We identified adult patients with HGRT (American Association for the Surgery of Trauma grade III-V) in TQIP (2013-2017). Propensity scoring was used to adjust for the probability of nephrectomy. Conditional logistic regression was used to analyze the association between nephrectomy and mortality and AKI. We adjusted for patient characteristics, injury specifics, and physiological factors including blood transfusions. RESULTS: There were 12,780 patients with HGRT, and 1,014 (7.9%) underwent nephrectomy. Mortality was 10.6% and 4.2% in the nephrectomy and nonnephrectomy groups, respectively (p <0.001). In nephrectomy patients, 8.6% experienced AKI vs 2.4% of nonnephrectomy patients (p <0.001). In the adjusted analysis, there was no association between nephrectomy and mortality (OR=0.367, 95% CI 0.09-1.497, p=0.162). There was also no association between nephrectomy and AKI. Increasing age, nonCaucasian race, increasing Injury Severity Score, decreasing Glasgow Coma Score and blood transfusions were associated with higher mortality. For AKI, independent predictors included increasing age, male sex, and blood transfusions. CONCLUSIONS: After adjusting for volume of blood transfused in the first 24 hours, nephrectomy after HGRT was not associated with increased mortality or AKI. As a clinical principle, trauma nephrectomy should be avoided when possible.

Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry.

BACKGROUND: Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy. METHODS: The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (<6 vs ≥6 hours) or urgent (<24 vs ≥24 hours) intervals. RESULTS: A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (<6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (<24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke. CONCLUSIONS: In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.

Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt Trauma.

Background Multidetector CT (MDCT) enables rapid and accurate diagnosis of head and neck (HN) injuries in patients with blunt trauma (BT). However, MDCT is overused, and appropriate selection of patients for imaging could improve workflow. Purpose To investigate the effect of implementing clinical triaging algorithms on use of MDCT in the HN in patients who have sustained BT. Materials and Methods In this retrospective study, patients aged 15 years or older with BT admitted between October 28, 2007, and December 31, 2013, were included. Patients were divided into pre- and postalgorithm groups. The institutional trauma registry and picture archiving and communication system reports were reviewed to determine which patients underwent MDCT of the head, MDCT of the cervical spine (CS), and MDCT angiography of the HN at admission and whether these examinations yielded positive results. Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score (only those patients in the intensive care unit), length of hospital stay (LOS), length of intensive care unit stay (ICULOS), and mortality were obtained from the trauma registry. Results A total of 8999 patients (mean age, 45 years ± 20 [standard deviation]; age range, 15-101 years; 6027 male) were included in this study. A lower percentage of the postalgorithm group versus the prealgorithm group underwent MDCT of the head (55.8% [2774 of 4969 patients]; 95% CI: 54.4, 57.2 vs 64.2% [2589 of 4030 patients]; 95% CI: 62.8, 65.7; P < .001) and CS (49.4% [2452 of 4969 patients]; 95% CI: 48.0, 50.7 vs 60.5% [2438 of 4030 patients]; 95% CI: 59.0, 62.0; P < .001) but not MDCT angiography of the HN (9.7% [480 of 4969 patients]; 95% CI: 8.9, 10.5 vs 9.8% [393 of 4030 patients]; 95% CI: 8.9, 10.7; P > .99). Pre- versus postalgorithm groups did not differ in LOS (mean, 4.8 days ± 7.1 vs 4.5 days ± 7.1, respectively; P = .42), ICULOS (mean, 4.6 days ± 6.6 vs 4.8 days ± 6.7, respectively; P > .99), or mortality (2.9% [118 of 4030 patients]; 95% CI: 2.5, 3.5; vs 2.8% [141 of 4969 patients]; 95% CI: 2.4, 3.3; respectively; P > .99). Conclusion Implementation of a clinical triaging algorithm resulted in decreased use of multidetector CT of the head and cervical spine in patients who experienced blunt trauma, without increased adverse outcomes. © RSNA, 2021 See also the editorial by Munera and Martin in this issue.

Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS: Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS: The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.

Improved outcomes of endovascular repair of thoracic aortic injuries at higher volume institutions.

BACKGROUND: The use of thoracic endovascular aortic repair (TEVAR) has significantly improved the ability to treat traumatic aortic injuries (tTEVAR). We sought to determine whether a greater center volume correlated with better outcomes. METHODS: Vascular Quality Initiative data of TEVAR (2011-2017) for trauma were used in the present analysis. Using the distribution of the annual case volume at the participating centers, the sample was stratified into three terciles. In-hospital mortality at high-volume centers (HVCs) and low-volume centers (LVCs) was compared after adjustment for risk factors established in our previous Vascular Quality Initiative-based risk model containing age, gender, renal impairment, left subclavian artery involvement, and select concomitant injuries. RESULTS: A total of 619 tTEVAR cases were studied across 74 centers. HVCs (n = 184 cases) had performed ≥4.9 cases annually and LVCs (n = 220 cases) had performed ≤2.4 cases annually. Both crude mortality (4.4% vs 8.6%; P = .22) and adjusted odds of mortality (odds ratio, 0.44; 95% confidence interval, 0.18-1.09; P = .08) showed a trend toward better outcomes for tTEVAR performed at HVCs than at LVCs. The addition of center volume to our previous multivariate model significantly improved its discriminative ability (C-statistic, 0.90 vs 0.88; P = .02). The overall TEVAR volume (for all indications) was not associated with increased odds of mortality for tTEVAR (odds ratio, 0.46; 95% confidence interval, 0.17-1.20; P = .11), nor did it improve the model's discriminative ability. CONCLUSIONS: Higher volume centers showed improved perioperative mortality after tTEVAR. The thoracic aortic trauma volume was more predictive than the overall TEVAR volume, suggesting that technical expertise is not the driving factor. Stable patients might benefit from transfer to a higher volume center before repair.

Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is an effective treatment of blunt thoracic aortic injury (BTAI). However, the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications. METHODS: The Vascular Quality Initiative registry was queried from 2013 to 2019 to identify patients who had undergone TEVAR for BTAI with or without the administration of intraoperative heparin. Univariate analyses were performed with the Student t test, Fisher exact test, or χ2 test, as appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality. RESULTS: A total of 655 patients were included, of whom most had presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) of ≥15 (70.2% vs 90.5%; P < .0001) or major head or neck injury (39.6% vs 62.9%; P < .0001). Patients receiving heparin also had a lower incidence of inpatient death (5.1% vs 12.9%; P < .01). Across all injury grades, heparin use was not associated with the need for intraoperative transfusion or postoperative transfusion or the development of hematoma. In patients with grade III BTAI, the nonuse of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%; P < .05). On multivariable logistic regression analysis for inpatient mortality, intraoperative heparin use (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P < .05) and female gender (OR, 0.11; 95% CI, 0.11-0.86; P < .05) were associated with better survival, even after controlling for head and neck trauma and injury grade. In contrast, increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), postoperative transfusion (OR, 1.06; 95% CI, 1.02-1.11; P < .01), higher ISS (OR, 1.04; 95% CI, 1.01-1.07; P < .05), postoperative dysrhythmia (OR, 4.48; 95% CI, 1.10-18.18; P < .05), and postoperative stroke or transient ischemic attack (OR, 5.54; 95% CI, 1.11-27.67; P < .05) were associated with increased odds of inpatient mortality. CONCLUSIONS: Intraoperative heparin use was associated with reduced inpatient mortality for patients undergoing TEVAR for BTAI, including those with major head or neck trauma and high ISSs. Heparin use did not increase the risk of hemorrhagic complications across all injury grades. Also, in patients with grade III BTAI, heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI and should be administered when no specific contraindication exists.

Independent predictors of mortality for patients with traumatic renal injury.

PURPOSE: To investigate the parameters of renal trauma, including emergent intervention type, that predict the mortality of patients with traumatic renal injury. METHODS: A retrospective database analysis was performed on patients who sustained a traumatic renal parenchymal injury identified by the 2017 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, ER and hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score, renal injury grade, and need for emergent intervention (angioembolization versus open surgery). Logistic regression was used to correlate intervention type and trauma parameters to mortality. RESULTS: A total of 4,876 of 1,004,440 trauma patients (0.49%) had a traumatic renal injury. Of those, 220 (4.5%) underwent an emergent intervention-29 (0.59%) angioembolization and 191 (3.9%) open renal surgery. 83 patients with a blunt renal trauma (2.0%) underwent renal intervention, whereas 136 (21.0%) with a penetrating injury required a procedure. Forty-five of the 220 patients (20.5%) who had a renal intervention died, while 377 of 4,656 (8.1%) who did not have an intervention died. Multiple logistic regression identified black race, age > 45 years, penetrating trauma, and ISS > 15 to be independent predictors of mortality. Neither angioembolization nor open renal surgery was associated with a significantly higher likelihood of mortality in the multivariable model. CONCLUSION: While procedural interventions are associated with higher mortality for patients with traumatic renal injury, other factors, such as race, age, trauma type, and injury severity may be more predictive of death under care.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

BACKGROUND: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.