Outcomes after celiac artery coverage during thoracic endovascular aortic aneurysm repair.

OBJECTIVE: Coverage of celiac artery (CA) during thoracic endovascular aortic aneurysm repair (TEVAR) has been performed to extend the distal seal zone for which preliminary results and short-term follow-up have been reported. We aim to show the outcomes up to 81 months after CA coverage during TEVAR. METHODS: Patients undergoing TEVAR with coverage of the CA origin from 2005 to 2013 were retrospectively analyzed. Points of analysis include indications for covering the CA, demonstration of collateral circulation between the CA and superior mesenteric artery (SMA), anatomic features of the distal landing zone, rate of reintervention, technical success, presence of clinical ischemic symptoms after the procedure, and mortality. RESULTS: During the 9-year period, 366 patients underwent TEVAR, 18 (5%) of whom had CA coverage. Eleven (61%) had TEVAR with CA coverage due to a thoracic aneurysm, three (17%) had thoracic aortic dissection related to aneurysm, and four (22%) had previous TEVAR with a type Ib endoleak (EL) requiring distal coverage. Mesenteric angiography in preparation for TEVAR with CA coverage diagnosed a critical SMA stenosis in one patient that was treated with stenting before the index procedure. At the conclusion of the indicated procedure, two patients (11%) had a type Ia EL and two patients (11%) had a type Ib EL. Three of the type I ELs required reintervention. Two patients (11%) had a type II EL, both of which were managed with observation and resolved. Reintervention was required in 27% of patients. Postoperative complications included visceral ischemia in 2 (11%), weight loss in 1 (5%), spinal cord ischemia in 2 (11%), a cerebrovascular event in 1 (6%), and death in 1 (6%). The mean follow-up period was 38 months (range, 0.5-81 months). CONCLUSIONS: This analysis of outcomes up to 81 months supports the suitability of covering the CA in selected patients for extending the distal landing zone to the visceral aortic level above the SMA or when alternative branch vessel treatment is unavailable. Preoperative angiographic evaluation of the mesenteric collaterals and early postoperative surveillance may limit postoperative complications. Once the CA is covered, new symptoms do not develop unless the SMA is compromised.

Is helicopter evacuation effective in rural trauma transport?

Helicopter transport for trauma remains controversial because its appropriate utilization and efficacy with regard to improved survival is unproven. The purpose of this study was to assess rural trauma helicopter transport utilization and effect on patient survival. A retrospective chart review over a 2-year period (2007-2008) was performed of all rural helicopter and ground ambulance trauma patient transports to an urban Level I trauma center. Data was collected with regard to patient mortality and Injury Severity Score (ISS). Miles to the Level I trauma center were calculated from the point where helicopter or ground ambulance transport services initiated contact with the patient to the Level I trauma center. During the 2-year period, 1443 rural trauma patients were transported by ground ambulance and 1028 rural trauma patients were transported by helicopter. Of the patients with ISS of 0 to 10, 471 patients were transported by helicopter and 1039 transported by ground. There were 465 (99%) survivors with ISS 0 to 10 transported by helicopter with an average transport distance of 34.6 miles versus 1034 (99.5%) survivors with ISS 0 to 10 who were transported by ground an average of 41.0 miles. Four hundred and twenty-one patients with ISS 11 to 30 were transported by helicopter an average of 33.3 miles with 367 (87%) survivors versus a 95 per cent survival in 352 patients with ISS 11 to 30 who were transported by ground an average of 39.9 miles. One hundred and thirty-six patients with ISS > 30 were transported by helicopter an average of 32.8 miles with 78 (57%) survivors versus a 69 per cent survival in 52 patients with ISS > 30 who were transported by ground an average of 33.0 miles. Helicopter transport does not seem to improve survival in severely injured (ISS > 30) patients. Helicopter transport does not improve survival and is associated with shorter travel distances in less severely injured (ISS < 10) patients in rural areas. This data questions effective helicopter utilization for trauma patients in rural areas. Further study with regard to helicopter transport effect on patient survival and cost-effective utilization is warranted.

Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth.

OBJECTIVE: The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." METHODS: During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." RESULTS: During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"' were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." CONCLUSIONS: In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.