Four-year Surgical Results for

Traumatic Aortic Injury in

China Medical University Hospital, Mid-Taiwan

Yi-Chun Lin 林怡均 (5th grade medical student),

MingLi Li 李明禮, Chih-Hsiang Hsu, Ching-Feng Wu, Hui-Han Lin

Cardiovascular Division, Surgery Department, China Medical University Hospital, Taichung City, Taiwan

LINC Asian-pacific 2019

Hong Kong

March 12(Tue)-13(Wed) 2019

Speaker name: Yi-Chun Lin

.................................................................................

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

Disclosure

Background

✓ Blunt traumatic aortic injury (BTAI) carries a high mortality rate up to 10-30% [1]

✓ Urgent TEVAR is mandatory for Grade II to IV blunt traumatic aortic injuries. [2]

[1] Aorta, July 2013, Vol.1, Issue 2: 117–122[2] Journal of Vascular Surgery 2009, Vol.49, 1403-08

• Grade I : intimal tear/flap

• Grade II : intramural hematoma

• Grade II’: AORTIC DISSECTION

• Grade III : pseudoaneurysm

• Grade IV: rupture

• Grade X : PERIAORTIC HEMATOMAEndovascular Today 2014, 38-42.

1. Accuracy of BTAI diagnosis and grading

2. Surgical strategy and results in our center

3. Analysis of mortality causes,

complications and reinterventions

4. Aortic remodeling after TEVAR

Aim

Jan. 2015 – Jan. 2019

all patients performed TEVAR for BTAI.

Retrospective review of

Initial data Operative Data Post-operation Diagnostic data

Mechanism of injury Operation time Length of ICU stay Grade of aortic injury

Associated injury Number of stents Length of ward stay Pre-operative CXR

Injury severity score Tapered stent usage Early complication Pre-operative CT

Glasgow coma scale Diameter of stents Late complication CT after operation

Initial / lowest BP Proximal landing Early reintervention False lumen thrombosis

Initial heart rate Proximal landing Late reintervention Change of aortic diameter

Comorbidity LSCA coverage Mortality cause

Door to operation time Associated operation Operation to mortality time

BP: blood pressure LSCA: left subclavian artery ICU: intensive care unit CXR: chest X-ray CT: computed tomography

Method

False Lumen Thrombosis

43 BTAI

Gr 2

1Type A

IMH

4Type B

IMH

Gr 2’

4Type A

dissection

7Type B

dissection

Gr 3

15Pseudo-

aneurysm

Gr 4

8 Contained

rupture

Gr X

4 Periaortic hematoma

IMH: intramural hematoma

BTAI Grading

17 y/o Malescooter vs car

17 y/o Male scooter vs car

22 y/o Male scooter vs car

72 y/o Male car vs electric pole

Periaortic hematoma

Fall

23%Motorcycle

Crash

54%

Bike

Crash

2% Car

Crash

12%

Pedestrian

7%Other: hit

by electric

cable

2%

0 10 20 30

Lung

Sternal and Ribs

Abdomen

Brain

Extremity

Spine

Pelvis

Facial bone

28

19

18

17

17

14

11

3

PERSON

Pre-operative Results

Mechanism of Injury Associated Injury

Injury Severity Score (ISS): 31±9

Age 52.8 ± 17.6

Male 34 (79.07%)

Comorbidities

Hypertension 15 (34.88%)

Cigarette 13 (30.23%)

CVA 1 (2.33%)

DM 7 (16.28%)

Medication

Antiplatelet 2 (4.65%)

Pre-operative Results

Pre-operation CXR

0 10 20 30 40

Widened mediastinum

Indistinct aortic knob

Deviation of trachea

Ribs/Clavical/Scapula fracture

cardiomegaly

Pleural effusion

Hemothorax

Deviation of NG

Traumatic pulmonary edema

Tracheal compression

Lung contusion

Compression of bronchus

Apical cap

37

37

11

9

6

5

4

2

2

1

1

1

1

Door to Operation Time

BTAI (43) BAAD (46)

Age 52.8 ± 17.6 55.3 ± 13.3

Operation time 100.9 min 124.5 min

Number of graft 2 (64.3%) 2 (71.7%)

Tapered graft 37.5% 26.1%

Proximal diameter

28 mm (34.5%) 34 mm (26.1%)

Distal diameter 24 mm (30%) 28 mm (39.1%)

Proximal landing ≥ Zone3 (52.4%) Zone2 (52.2%)

Distal landing T8 (26.8%) / T9 (22.0%) T8 (56.5%)

Management of LSA coverage

23.8% TAE 2 / rChim 6 / aChim 1/ fenestration 1/ covered 2

54.3% TAE 2/ rChim 18/ aChim3/ fenestration 1/ ligate 1

Operation

BAAD: acute Type B aortic dissection TAE: trans-arterial embolization rChim: reversed chimney aChim: antegrade chimney

CPCR 3 Exploratory laparotomy 10

ECMO 2 Limb ORIF 10

CSF drainage 2 ICP monitor 8

PTA 1 EVD 2

LCCA chimney 1 Craniectomy 2

INMA chimney 2 Craniotomy 2

RSA chimney 1 Bowel resection 1

Fenestration of arch land 1 Splenectomy 1

Associated Procedure &

Combined Surgery

BTAI BAAD

30-day Mortality 13/43 (30.2%) 4/46 (8.7%)

Procedure-related 5/43 (11.6%) (free rupture 3) 2/46 (4.3%)

Brain injury 5/43 (11.6%) 2/46 (4.3%)

Lung 1/43 (2.3%) Tension pneumothorax 1 0

Abdomen2/43 (4.7%)Visceral ischemia 1/Intraabdominal bleeding 1

0

Early complication7.1% Type A AD with aortic valve entrapment 1Type A AD AKI 2

15.2%

Reintervention3.3 %RSA to LSA due to LSA steal syndrome 1

23.9 %

Surgical Results

Analysis of Mortality

Grade

Gr II Gr II' Gr III Gr IV Gr X

A

IMH

B

IMH

Type A

AD

Type B

AD

Pseudo-

aneurysm

Contained

rupture

Periaortic

hematoma

Mortality no. 1 / 1 1 / 4 3 / 4 2 / 7 2 /15 4 /8 0

Type Management Outcome / mortality cause

A IMH Z4 TEVAR mortalityPre-operative spinal shock,

medulla infarction

A AD Asc. Ao grafting + Z3 TEVARMBD in 26 day,

persistent patent false lumen at arch

A AD Z0 TEVAR mortalitySevere AR, related to

aortic valve entrapment

A ADTotal arch replacement + Z2

TEVAR + LSCA aChimneymortality

Pre-operative cerebellum

infarction

A AD Z0 TEVAR +INMA rChimney mortality True lumen collapse

A 79 y/o female falling from stairsGr II Type B IMH

A 59 y/o male falling from 2nd floorGr II’ Type A Aortic Dissection

Gr4 AR

A 42 y/o male with motor-vehicle-crashGr IV Contained rupture

False Lumen Thrombosis

Grade

Gr II Gr II' Gr III Gr IV Gr X

IMH ADPseudo-

aneurysm

Contained

Rupture

Periaortic

hematoma

Follow-up

person2 6 9 2 3

0a 0 33.3% 0 0 0

I 0 33.3% 0 0 0

IIb 0 16.7% 0 0 0

III 100% 16.7% 100% 100% 100%

Discussion

[3] J Trauma 2010 Feb;68(2):463-70[4] J Surg Res. 2017 Nov,219:77-71[5] J Thoracic and Cardiovascular Surgery 2017 Feb; Volume 153, 2

CorrelationsMortality rate

In this study Literature study

Injury severity score(Japan 2010)

30.2% when ISS 31 27.2% when ISS≥36

Traumatic brain injury (USA registry 2017)

29.4% 19.3-35.8%

TEVAR for ascending aorta pathology

Traumatic 80%Non-traumatic

8.3%

1. Disrupted intercostal arteries, azygos vein and IVC may mimic BTAI

2. TEVAR for BTAI is always a dilemma in multiple traumatic patients

3. Strategy for BTAI with ascending aortic pathology needs further evaluation

4. Promising aortic remodeling for Gr III-IV BTAI after TEVAR procedure

Conclusion

Yi-Chun Lin 林怡均, MingLi Li 李明禮,

Cardiovascular Division, Surgery Department, China Medical University Hospital, Taichung City, Taiwan

LINC Asian-pacific 2019

Hong Kong

March 12(Tue)-13(Wed) 2019

Thank you for your attention