Trauma cerrado de aorta torácica, desde el servicio de urgencias hasta el quirófano: revisión narrativa / Blunt trauma of the thoracic aorta, from the emergency department to the operating room: narrative review / Trauma contuso da aorta torácica: do pronto-socorro ao centro cirúrgico, uma revisão narrativa

El trauma es la principal causa de muerte de la población en edad productiva. El abordaje del trauma torácico cerrado todavía es un desafío para el médico de urgencias. Aunque no es una entidad frecuente, se asocia con una alta mortalidad y resultados adversos. El diagnóstico del trauma cerrado de aorta torácica (LCAT) requiere un alto índice de sospecha, dado que los signos y síntomas no son específicos de esta enfermedad (dolor torácico, dolor interescapular, disnea, disfagia, estridor, disfonía). Es importante resaltar que la ausencia de inestabilidad hemodinámica no debe descartar una lesión aórtica. Para su diagnóstico imagenológico se debe tener en cuenta que los rayos X de tórax no tienen el rendimiento adecuado, el patrón de referencia es la angiotomografía y el ecocardiograma transesofágico (ETE) constituye una opción diagnóstica. El manejo incluye líquidos endovenosos y antihipertensivos como medida transitoria, manejo quirúrgico definitivo y, en algunos casos, manejo expectante o diferido. Los pacientes inestables o con signos de ruptura inminente deben ser llevados de manera inmediata a cirugía. El manejo quirúrgico temprano ha impactado en la mortalidad. A pesar de los avances en las técnicas quirúrgicas, la técnica quirúrgica abierta documenta mayor tasa de mortalidad que el manejo endovascular, el cual tiene numerosas ventajas al ser poco invasivo. Esta es una revisión narrativa que destaca algunos aspectos clave sobre los mecanismos de lesión, diagnóstico y manejo inicial del trauma cerrado aorta torácica. Por último, se propone un algoritmo de abordaje de trauma de aorta.

Trauma is the leading cause of death in the productive-age population. Addressing blunt chest trauma is still a challenge for the emergency physician. Although it is not a common entity, it is associated with high mortality and adverse outcomes. The diagnosis of blunt thoracic aortic trauma (LCAT) requires a high index of suspicion, given that the signs and symptoms are not specific to this disease (chest pain, interscapular pain, dyspnea, dysphagia, stridor, dysphonia). It is important to highlight that the absence of hemodynamic instability should not rule out aortic injury. For its imaging diagnosis, it must be taken into account that chest X-rays do not have adequate performance; the reference standard is angiotomography and transesophageal echocardiography (TEE) is a diagnostic option. Management includes intravenous fluids and antihypertensives as a temporary measure, definitive surgical management and, in some cases, expectant or deferred management. Unstable patients or patients with signs of imminent ruptura should be taken immediately to surgery. Early surgical management has impacted mortality. Despite advances in surgical techniques, the open surgical technique documents a higher mortality rate than endovascular management, which has numerous advantages as it is minimally invasive. This is a narrative review that highlights some key aspects about the mechanisms of injury, diagnosis and initial management of blunt thoracic aortic trauma. Finally, an algorithm for addressing aortic trauma is proposed.

O trauma é a principal causa de morte na população em idade produtiva. Abordar o trauma torácico contuso ainda é um desafio para o médico emergencista. Embora não seja uma entidade comum, está associada a alta mortalidade e resultados adversos. O diagnóstico de trauma fechado de aorta torácica (TACE) requer alto índice de suspeição, visto que os sinais e sintomas não são específicos desta doença (dor torácica, dor interescapular, dispneia, disfagia, estridor, disfonia). É importante ressaltar que a ausência de instabilidade hemodinâmica não deve descartar lesão aórtica. Para seu diagnóstico por imagem deve-se levar em consideração que a radiografia de tórax não apresenta desempenho adequado; o padrão de referência é a angiotomografia e a ecocardiografia transesofágica (ETE) é uma opção diagnóstica. O manejo inclui fluidos intravenosos e anti-hipertensivos como medida temporária, manejo cirúrgico definitivo e, em alguns casos, manejo expectante ou diferido. Pacientes instáveis ou com sinais de ruptura iminente devem ser encaminhados imediatamente para cirurgia. O manejo cirúrgico precoce impactou a mortalidade. Apesar dos avanços nas técnicas cirúrgicas, a técnica cirúrgica aberta documenta maior taxa de mortalidade do que o manejo endovascular, que apresenta inúmeras vantagens por ser minimamente invasivo. Esta é uma revisão narrativa que destaca alguns aspectos-chave sobre os mecanismos de lesão, diagnóstico e manejo inicial do trauma contuso da aorta torácica. Finalmente, é proposto um algoritmo para tratar o trauma aórtico.

Lesões traumáticas de aorta em zona rural: série de casos com manifestações tardias e revisão dos aspectos terapêuticos / Traumatic aorta injuries in a rural area: late manifestations and review of therapeutic aspects

Resumo As lesões traumáticas da aorta (LTA) torácica estão associadas a altas taxas de morbimortalidade. São classificadas de acordo com a extensão do dano, e a angiotomografia computadorizada tem as maiores sensibilidade e especificidade para identificar o grau de lesão e potenciais lesões associadas. As estratégias terapêuticas para LTA são baseadas no tipo de lesão, na extensão e nas lesões associadas. Pode auxiliar na definição de conduta também o grau de estabilidade do paciente, podendo ser manejo cirúrgico convencional, endovascular (TEVAR) ou conservador em casos selecionados. Entre os pacientes com anatomia vascular adequada, a cirurgia endovascular está associada a melhor sobrevida e a menos riscos. O objetivo deste artigo foi descrever uma série de quatro casos acompanhados em serviço terciário, em um estado com poucos serviços de alta complexidade. A terapêutica endovascular foi empregada como método preferencial. Os pacientes apresentaram evolução favorável sem complicações até a alta e encontram-se em acompanhamento ambulatorial.

Abstract Traumatic thoracic aortic injuries (TTAI) are associated with high rates of morbidity and mortality. They are classified according to the extent of damage and computed tomography angiography has the highest sensitivity and specificity for identifying the degree of injury and potential associated lesions. Treatment strategies for TTAI are based on the type and extent of injury and associated lesions. The patient's degree of stability can also help to define the choice of treatment, which can be conventional or endovascular surgery (EVAR) or even conservative management in selected cases. Among patients with adequate vascular anatomy, endovascular surgery is associated with better survival and fewer risks. The objective of this article is to describe a series of four cases followed up at a tertiary service in a Brazilian state that has few centers that provide high complexity care. Endovascular therapy was employed as the preferred method. All four patients had favorable outcomes, with no complications up to discharge, and are currently in outpatient follow-up.

Vitamin E suppresses aortic ultrastructural alterations induced by toxic doses of monosodium glutamate / La vitamina E suprime las alteraciones ultraestructurales aórticas inducidas por dosis tóxicas de glutamato monosódico

SUMMARY: An association between certain food additives and chronic diseases is reported. Current study determined whether administering toxic doses of the food additive monosodium glutamate (MSG) into rats can induce aortopathy in association with the oxidative stress and inflammatory biomarkers upregulation and whether the effects of MSG overdose can be inhibited by vitamin E. MSG at a dose of (4 mg/kg; orally) that exceeds the average human daily consumption by 1000x was administered daily for 7 days to the rats in the model group. Whereas, rats treated with vitamin E were divided into two groups and given daily doses of MSG plus 100 mg/ kg vitamin E or MSG plus 300 mg/kg vitamin E. On the eighth day, all rats were culled. Using light and electron microscopy examinations, a profound aortic injury in the model group was observed demonstrated by damaged endothelial layer, degenerated smooth muscle cells (SMC) with vacuoles and condensed nuclei, vacuolated cytoplasm, disrupted plasma membrane, interrupted internal elastic lamina, clumped chromatin, and damaged actin and myosin filaments. Vitamin E significantly protected aorta tissue and cells as well as inhibited MSG-induced tissue malondialdehyde (MDA), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). The highest used vitamin E dosage was more effective. Additionally, a significant correlation was observed between the aortic injury degree and tissue MDA, TNF-α, IL-6, and superoxide dismutase (SOD) levels (p=0.001). Vitamin E effectively protects against aortopathy induced by toxic doses of MSG in rats and inhibits oxidative stress and inflammation.

RESUMEN: Se reporta una asociación entre ciertos aditivos alimentarios y enfermedades crónicas. El objetivo de este estudio fue determinar si la administración de dosis tóxicas del aditivo alimentario glutamato monosódico (MSG) en ratas puede inducir aortopatía en asociación con el estrés oxidativo y la regulación positiva de los biomarcadores inflamatorios y si el efecto de una sobredosis de MSG se puede inhibir con vitamina E. Se administró MSG diariamente durante 7 días una dosis de (4 g/kg; por vía oral) que excede el consumo diario humano promedio, en 1000x a las ratas del grupo modelo. Mientras que las ratas tratadas con vitamina E se dividieron en dos grupos y se administraron dosis diarias de MSG más 100 mg/kg de vitamina E o MSG más 300 mg/kg de vitamina E. Todas las ratas fueron sacrificadas en el octavo día. Usando exámenes de microscopía óptica y electrónica, se observó una lesión aórtica profunda en el grupo modelo demostrada por una capa endotelial dañada, células musculares lisas degeneradas (SMC) con vacuolas y núcleos condensados, citoplasma vacuolado, membrana plasmática rota, lámina elástica interna interrumpida, cromatina agrupada y filamentos de actina y miosina dañados. La vitamina E protegió significativamente el tejido y las células de la aorta, además de inhibir el malondialdehído tisular (MDA) inducido por MSG, la interleucina-6 (IL-6) y el factor de necrosis tumoral alfa (TNF-α). La dosis más alta de vitamina E utilizada fue más efectiva. Además, se observó una correlación significativa entre el grado de lesión aórtica y los niveles tisulares de MDA, TNF-α, IL-6 y superóxido dismutasa (SOD) (p=0,001). La vitamina E efectivamente protege contra la aortopatía inducida por dosis tóxicas de MSG en ratas e inhibe el estrés oxidativo y la inflamación.

Open Repair versus Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries : Short- and Mid-Term Outcomes / 日本心臓血管外科学会雑誌

Objective : The mainstream strategy for blunt traumatic thoracic aortic injuries (BTAI) has been shifting from conventional open repair (OR) to thoracic endovascular aortic repair (TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods : We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results : Eighteen cases were identified. Of these, 7 patients (38.9%, mean age 62.0±15.2 years) were treated with OR and 11 (61.1%, mean age 61.8±21.3 years) were treated with TEVAR. There was significant reduction in the mean operative duration (OR 444±145 vs TEVAR 65±14 min ; p＜0.001), the mean intraoperative blood loss (OR 2,787±1,578 vs TEVAR 210±376 ml ; p＜0.001), the volume of blood transfusions (OR 5,042±2,219 vs TEVAR 929±751 ml ; p＜0.001), and the mean dose of heparin infusion (OR 20.3±4.1 vs TEVAR 7.9±8.5 ml ; p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0% (p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate (average follow-up period of 42.0±56.9 months). Conclusions : Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.

Traumatic Aortic Dissection (Stanford Type A, DeBakey Type II) Caused by Blunt Chest Trauma / 日本心臓血管外科学会雑誌

We report the case of a 55-year-old man who received a hard blow to his chest from a liquid nitrogen hose that caused traumatic aortic dissection (Stanford type A, DeBakey type II). He did not have any other hemorrhagic injury ; therefore, we decided to perform an emergency surgery. The postoperative course was uneventful, and he was discharged on postoperative day 19. Pathological findings were compatible with traumatic aortic dissection. Blunt thoracic aortic injury is a potentially life-threatening injury ; therefore, it is worth remembering that relatively low-energy blunt trauma can cause aortic injury in patients with severe atherosclerosis. The optimal timing of intervention should be individualized in traumatic aortic injury with consideration of associated injuries.

Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury: A case report / 中华创伤杂志(英文版)

Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate of associated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 year-old-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.

Vanadium inhibits Type 2 diabetes mellitus-induced aortic ultrastructural alterations associated with the Inhibition of dyslipidemia and biomarkers of inflammation in rats / El vanadio inhibe las alteraciones ultraestructurales aórticas inducidas por la diabetes mellitus Tipo 2 asociadas con la inhibición de la dislipidemia y los biomarcadores de inflamación en ratas

The potential inhibitory effect of the insulin mimicking agent, vanadium on type 2 diabetes mellitus (T2DM)induced alterations to the aorta ultrastructure associated with the suppression of dyslipedima and biomarkers of inflammation has not been investigated before. Therefore, we tested whether vanadium can protect against aortic injury induced secondary to T2DM possibly via the inhibition of blood lipid and inflammatory biomarkers. T2DM was induced in rats by a high-fat diet and streptozotocin (50 mg/ kg), and the treatment group started vanadium treatment five days post diabetic induction and continued until being sacrificed at week 10. Using light and electron microscopy examinations, we observed in the model group substantial damage to the aorta tissue such as damaged endothelium, degenerative cellular changes with vacuolated cytoplasm and thickened internal elastic lamina that were substantially ameliorated by vanadium. Administration of vanadium to diabetic rats also significantly (p<0.05) reduced blood levels of glucose, hyperlipidemia and biomarkers of inflammation (TNF-a, IL-6). We conclude that vanadium protects against T2DM-induced aortic ultrastructural damage in rats, which is associated with the inhibition of blood sugar and lipid and inflammatory biomarkers.

El potencial efecto inhibidor del agente imitador de la insulina, el vanadio en las alteraciones inducidas por la diabetes mellitus tipo 2 (DM2) en la ultraestructura de la aorta, asociada con la supresión de dislipidemia y los biomarcadores de inflamación no se ha investigado anteriormente. El objetivo fue estudiar las propiedades del vanadio para proteger contra la lesión aórtica inducida a la DM2, a través de la inhibición de los lípidos sanguíneos y los biomarcadores inflamatorios. La DM2 fue inducida en ratas con una dieta alta en grasas y estreptozotocina (50 mg / kg), y el grupo de tratamiento fue sometido a un régimen continuo con vanadio, cinco días después de la inducción diabética hasta ser sacrificadas en la semana 10. Se utilizaron exámenes de luz y microscopía electrónica en el grupo modelo y se observó un daño sustancial al tejido de la aorta, como también en el endotelio; los cambios celulares degenerativos con citoplasma vacuolado y lámina elástica interna engrosada mejoró sustancialmente con vanadio. La administración de vanadio a ratas diabéticas también redujo significativamente (p <0,05) los niveles sanguíneos de la glucosa, hiperlipidemia y los biomarcadores de inflamación (TNFa, IL-6). En conclusión, el vanadio protege contra el daño ultraestructural aórtico inducido por T2DM en ratas, que es asociado con la inhibición del azúcar en la sangre y los biomarcadores de lípidos y de inflamatorios.

A Case of Ruptured Abdominal Aortic Aneurysm Induced by a Hard Blow to the Abdomen / 日本心臓血管外科学会雑誌

A 77-year-old man was transferred to our hospital with a complaint of a sudden abdominal pain after receiving a hard blow to the abdomen. Contrast-enhanced CT revealed rupture of the abdominal aortic aneurysm with a massive retroperitoneal hematoma. Because of severe hemorrhagic shock, he underwent graft replacement with a woven bifurcated graft through a median laparotomy on an emergent basis. His postoperative course was uneventful and now he is doing well 3 years after surgery. Most blunt abdominal aortic injuries are caused by high-energy trauma, such as motor vehicle collisions and fall injuries. Although body blow is considered as a low-energy trauma, abdominal aortic injury could be caused in patients with an abdominal aortic aneurysm.

Midterm follow-up results and postoperative aortic remodeling of blunt aortic injuries after endovascular treatment / 中国胸心血管外科临床杂志

@#Objective    To summarize the mid-term follow-up results and postoperative aortic remodeling of treating blunt aortic injuries (BAI) with thoracic endovascular aortic repair (TEVAR). Methods    A retrospective study was conducted on BAI patients treated with TEVAR, who were admitted into the Department of Vascular Surgery in Zhongshan Hospital, Affiliated to Fudan University between September 2003 and December 2015. There were 15 males and 9 females at an average age of 45.6±14.0 years. The mechanism of BAI was mainly auto car crash. Totally 25 entry tears were detected and most of them were located at the aortic isthmus. Results    Twenty-four BAI patients survived and eventually went through TEVAR. One patient died of pulmonary embolism 1 week post-TEVAR. Rate of technical success, clinical success and perioperative mortality was 100.0%, 95.8%, and 4.2%, respectively. Nineteen patients were followed up with a mean time of 35.1(13-87) months. All of them survived this period. Based on the follow-up imaging of CTA, 18 of them revealed no endoleak or stent migration, and 1 patient of transection still had perfusion of distal false lumen at the abdominal aorta. None of the aortic segments measured in this study showed expansion of ≥5 mm during follow-up. The aorta remodeled well in 94.7% of them. Conclusion    TEVAR for treating BAI appears feasible with high rates of technical and clinical success rates. The mid-term follow-up results seems satisfying, but the long-term results are yet to be assessed with further follow-up.

A case of missed blunt traumatic aortic injury (BTAI)

We are reporting a case of missed blunt traumatic aortic injury (BTAI). A 28 year male presented with chest pain following a motor vehicle accident. He was discharged following normal clinical signs and chest radiograph. The following day he complained of lower limb weakness. Traumatic aortic dissection was revealed via computer tomography (CT) of the thorax. BTAI cannot be ruled out with normal clinical signs and chest radiograph alone. CT thorax is mandatory to rule out BTAI in high impact chest injury.

EFFECTIVENESS EVALUATION OF THORACIC ENDOVASCULAR AORTIC REPAIR FOR BLUNT THORACIC AORTIC INJURY WITH HOSTILE STENT-GRAFT PROXIMAL LANDING ZONE / 中国修复重建外科杂志

OBJECTIVE: To explore the effectiveness of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) with hostile stent-graft proximal landing zone. METHODS: A retrospective analysis was made on the clinical data of 13 patients with BTAI with hostile stent-graft proximal landing zone treated by TEVAR between December 2007 and December 2014. There were 10 males and 3 females with the mean age of 44 years (range, 24-64 years). The imaging examination indicated Stanford type B aortic dissection in 7 cases, pseudoaneurysm in 3 cases, aneurysm in 1 case, and penetrating ulcer in 2 cases. According to the partition method of thoracic aortic lesion by Mitchell, 8 cases underwent stent-graft with left subclavian artery (LSA) coverage, 3 underwent chimney stents for LSA, and 2 for left common carotid artery (LCCA). In 2 cases receiving chimney TEVAR involving LCCA, one underwent steel coils at the proximal segment of LSA to avoid type II endoleak and the other underwent in situ fenestration for endovascular reconstruction of LSA. RESULTS: All TEVAR procedures were successfully performed. The mean operation time was 1.8 hours (range, 1-3 hours); the mean intraoperative blood loss was 120 mL (range, 30-200 mL); and the mean hospitalization time was 15 days (range, 7-37 days). No perioperative death and paraplegia occurred. The patients were followed up 3-30 months (mean, 18 months). Type I endoleak occurred in 1 case during operation and spontaneously healed within 6 months. Hematoma at brachial puncture site with median nerve compression symptoms occurred in 1 case at 3 weeks after operation; ultrasound examination showed brachial artery pseudoaneurysm and thrombosis, and satisfactory recovery was obtained after pseudoaneurysmectomy. No obvious chest pain, shortness of breath, left upper limbs weakness, numbness, and dizziness symptoms were observed. Imaging examination revealed that stentgraft and branched stent remained in stable condition. Meanwhile the blood flow was unobstructed. No lesions expanded and ruptured. No new death, bacterial infection, or other serious complications occurred. CONCLUSIONS: According to Mitchell method, individualized plan may be the key to a promising result. More patients and further follow-up need to be included, studied, and observed.

Surgical Strategy for Blunt Aortic Injury / 日本心臓血管外科学会雑誌

<b>Objective</b> : Blunt aortic injury often accompanies other organ injuries, and therefore requires an appropriate lifesaving surgical strategy. <b>Patients</b> : During the past 8 years, blunt aortic injury was reviewed, based on 5 lifesaving cases experienced in our hospital. There were 3 men and 2 women (aged 57-70, average 64.2). The Injury Severity Scores were 13-25 (an average of 17.2). <b>Intervention</b> : Regarding our strategy, stabilization of vital signs should be at first aimed by intensive primary care, concomitantly with diagnostic procedures. When stabilization of vital signs is obtained, a delayed operation would be considered after damage control resuscitation. As for 3 of these 5 cases, an emergency surgery was performed because of distinct aortic hemorrhage with instability of vital signs, and stent graft repair was applied based on anatomical indication in two cases. In the other 2 cases, primary diagnosis suggested aortic injury by the bone fracture pieces. Damage control was conducted following stabilization of vital signs, and delayed surgery was done with removal of the bone fracture pieces and repair of aortic injury, which improved activities of daily living. <b>Results</b> : All cases recovered with no particular complication, and were discharged on 9-32 days average postoperatively. <b>Conclusion</b> : Blunt aortic injury is often fatal, but the appropriate diagnosis and treatment can play an important role in obtaining the good results.

Clinical progress in blunt aortic injury / 第二军医大学学报

Blunt aortic injury refers to damage to the aorta caused by sudden and strong force, which can be life-threatening and is not uncommon in recent years. To improve the survival of these victims remains a clinical challenge to date. This paper reviewed the pathophysiology, disease course, clinical manifestation, diagnosis and the treatment of blunt aortic injury, hoping to provide reference for a better understanding of this severe trauma and help the early diagnosis and management.

Understanding traumatic blunt cardiac injury.

Cardiac injuries are classified as blunt and penetrating injuries. In both the injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac injuries (BCI) are much more common than penetrating injuries. Aiming at a better understanding of BCI, we searched the literature from January 1847 to January 2012 by using MEDLINE and EMBASE search engines. Using the key word "Blunt Cardiac Injury," we found 1814 articles; out of which 716 articles were relevant. Herein, we review the causes, diagnosis, and management of BCI. In conclusion, traumatic cardiac injury is a major challenge in critical trauma care, but the guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management is mandatory.

Blunt Aortic Injury: Changing the First Treatment Modality / 대한내과학회지

The incidence of blunt aortic injury is on the rise worldwise because of vehicular trauma. Historically, open repair was the only treatment of option. However, after developing of stent graft, endovascular repair has become more common and preferred treatment for aortic injury.

Debranched Thoracic Endovascular Aortic Aneurysm Repair in a Case of Blunt Aortic Injury / 日本心臓血管外科学会雑誌

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury (BAI) by contrast computed tomography (CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.

Endovascular and open repair for blunt aortic injury, treated in one clinical institution in Brazil: a case series

OBJECTIVE: The objective of this retrospective study is to analyze and compare the results of conventional surgical repair and endovascular treatment of blunt aortic injury over the past 8 years. METHODS: Twenty-eight patients (25 male; mean age, 35 years) were treated for blunt aortic injury between April 2001 and March 2009 in a university hospital in Brazil. Twenty-six patients were included in the study: five were treated with operative repair (OR) and 21 with endovascular treatment (TEVAR). Two patients were excluded from analysis: one was managed conservatively, and one was treated with endovascular treatment for chronic dissection related to aortic trauma. RESULTS: Mean age was lower in the OR group than in the endovascular treatment group (17.8 vs. 38 years, P = .003). There was one death in the OR group and four deaths in the endovascular treatment group. Mean follow-up for the overall group was 33.6 months, with 48.7 months (range 8-83 months) for the OR group, and 29.8 months (range 2-91 months) for the TEVAR group. Mean time elapsed from injury to repair was 23.4 hours (range 8-48 h, median 20 h) for the OR group and 30.3 hours (range 2-240 h, median 18 h) for the TEVAR group (P = .374). The duration of surgery was shorter in the endovascular treatment group (142 versus 237 minutes; P = .005). There were no significant differences with respect to the number of postoperative days requiring mechanical ventilation, duration of ICU stay or duration of hospital stay. CONCLUSION: In this retrospective analysis, endovascular treatment was a safe method for repair of blunt aortic trauma, with immediate and midterm results that were comparable to those results obtained with operative repair. No complications from the stent graft were identified during follow-up. Nevertheless, long-term follow-up is necessary to confirm the effectiveness of this treatment.

Aortic injury associated with trocar insertion during laparoscopic-assisted vaginal hysterectomy: A case report

Aortic injury during laparoscopic procedures is a rare but life-threatening complication if not recognized and swiftly treated. We report our experience with a 47-year-old woman presenting with an aortic puncture of the anterior wall from a trocar insertion during a laparoscopic-assisted vaginal hysterectomy (laparoscopic hysterectomy). Diagnosis was delayed because of the limited vision of the laparoscope and the tamponade effect produced by the pneumoperitoneum. Anesthesiologists should be aware of the risk of iatrogenic major vessel injury during trocar insertion.

Penetrating Aortic Root Injury / 日本心臓血管外科学会雑誌

The patient was a 25-year-old man, who had been stabbed with a weapon siarilar to long ice pick. Thirty minutes later, he was admitted to our emergency center by ambulance. Anchocardiogram on admission revealed moderate pericardial effusion with normal heart function. Contrast medium enhanced computed tomography revealed that the weapon had entered from the left anterolateral chest wall and reached the posterior wall of the aortic root, approximately 1 cm above the left coronary artery orifice, through the left lung. During examinations, he suddenly went into shock and emergency open pericardial drainage was performed immediately. Approximately 400 ml of blood with a clot was removed from the pericardial cavity. After this procedure, there was no continuous bleeding. Subsequently, pseudoaneurysm developed at the aortic root injury site. Twenty seven days later, aortic surgery was performed. The injury site was resected and sutured directly, employing 4-0 polypropylene sutures with felt pledgets. He was discharged 14 days after the operation without any complications.