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Medline ® Abstracts for References 5-14

of 'Surgical and endovascular repair of blunt thoracic aortic injury'

5
TI
Comparative effectiveness of the treatments for thoracic aortic transection [corrected].
AU
Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM
SO
J Vasc Surg. 2011;53(1):193.
 
OBJECTIVES: To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection.
METHODS: We searched electronic databases (MEDLINE, EMBASE Cochrane, Web of Science, and Scopus) for studies that enrolled patients with aortic transection and measured the outcomes of interest. Two reviewers determined study eligibility and extracted data. We estimated the event rate associated with the different approaches from case series and the relative risk from comparative studies. Estimates from each study were pooled using the random effects model.
RESULTS: We found 139 studies that fulfilled the inclusion criteria, the majority of which were noncomparative surgical case series, retrospective, and none were randomized. Studies included 7768 patients, the majority of which were males. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair and nonoperative management (9%, 19%, and 46%, respectively, P<.01). No significant difference in event rate across the three groups was noted for the outcomes of anterior stroke, posterior stroke, or any stroke. The risk of spinal cord ischemia and end-stage renal disease were higher in open repair compared with the other 2 groups (9% vs 3% and 3%, P = .01 for spinal cord ischemia and 8% vs 5% and 3%, P = .01 for end-stage renal disease). Compared with endovascular repair, open repair was associated with an increased risk of graft infection and systemic infections. Meta-analyses of comparative studies demonstrated that compared with open repair, endovascular repair is associated with reduced mortality and spinal cord ischemia (relative risk, 0.61; 95% confidence interval, 0.46-0.80; and relative risk, 0.34; 95% confidence interval, 0.16-0.74; respectively). Inferences are limited by methodological quality, survival, and publication biases.
CONCLUSIONS: Very low-quality evidence suggests that, compared with open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, and graft and systemic infections. Nonoperative management is associated with the least favorable outcomes.
AD
Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, MN, USA. Murad.Mohammad@mayo.edu
PMID
6
TI
Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.
AU
Xenos ES, Abedi NN, Davenport DL, Minion DJ, Hamdallah O, Sorial EE, Endean ED
SO
J Vasc Surg. 2008;48(5):1343. Epub 2008 Jul 15.
 
OBJECTIVES: Traumatic thoracic aortic injuries are associated with high mortality and morbidity. These patients often have multiple injuries, and delayed aortic repair is frequently used. Endoluminal grafts offer an alternative to open surgical repair. We performed a meta-analysis of comparative studies evaluating endovascular vs open repair of these injuries.
METHODS: A systematic search of studies reporting treatment of traumatic aortic injury was performed using the following databases: Medline/PubMed, CINAHL, Proquest, Up to Date, Database of Abstracts of Reviews of Effects (DARE), ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Search terms were thoracic aortic trauma, traumatic thoracic aortic injury, traumatic aortic rupture, stent graft repair, and endovascular repair. Outcomes analyzed were procedure-related mortality, overall 30-day mortality, and paraplegia/paraparesis rate using odds ratios (OR) and 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Assessment of homogeneity was performed using the Q test; statistical heterogeneity was considered present at P<.05. Weighted averages of age, intervalto repair, and injury severity score were compared with the Welch t test; P<.05 was considered statistically significant.
RESULTS: Seventeen retrospective cohort studies from 2003 to 2007 were included. All were nonrandomized; no prospective randomized trials were found. These studies reported on 589 patients; 369 were treated with open repair, and 220 underwent thoracic stent graft placement. There was no significant difference in age (mean 38.8 years for both) or interval to repair (mean 1.5 days for endoluminal repair; 1 day for open repair). Injury severity score was higher for patients undergoing endoluminal repair (mean, 42.4 vs 37.4 for open repair, P<.001). Procedure-related mortality was significantly lower with endoluminal repair (OR, 0.31; 95% CI, 0.15-0.66; P = .002). Overall 30-day mortality was also lower after endoluminal repair (OR, 0.44; 95% CI, 0.25-0.78; P = .005). Sixteen studies reported data for postoperative paraplegia; 215 patients were treated with endograft placement and 333 with open repair. The risk of postoperative paraplegia was significantly less with endoluminal repair (OR, 0.32; 95% CI, 0.1-0.93; P = .037). The Q test did not indicate significant heterogeneity for the outcomes of interest; publication bias was limited.
CONCLUSIONS: Meta-analysis of retrospective cohort studies indicates that endovascular treatment of descending thoracic aortic trauma is an alternative to open repair and is associated with lower postoperative mortality and ischemic spinal cord complication rates.
AD
Department of Surgery, University of Kentucky, Lexington, KY 40536-0293, USA. esxeno2@email.uky.edu
PMID
7
TI
Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis.
AU
Tang GL, Tehrani HY, Usman A, Katariya K, Otero C, Perez E, Eskandari MK
SO
J Vasc Surg. 2008;47(3):671.
 
OBJECTIVE: Stent grafting has become the first-line approach to traumatic thoracic aortic transections (TTAT) in some trauma centers due to a perceived decrease in morbidity and mortality compared with standard open repair. We reviewed contemporary outcomes of patients undergoing endovascular repair of TTAT (endoTTAT) and those undergoing open repair (openTTAT) to determine if current reported results support first-line use of endoTTAT.
METHOD: Retrospective, nonrandomized studies published in English (>5 cases/report) involving TTAT listed in PubMed between 2001 and 2006 were systematically reviewed. Periprocedural outcomes between endoTTAT and openTTAT were analyzed. Mean follow-up was 22.9 months for endoTTAT (reported for 22 of 28 studies) and 48.6 months for openTTAT (reported for 5 of 12 studies). For statistical analysis, t tests were used.
RESULTS: We analyzed 33 articles reporting 699 procedures in which 370 patients treated with endoTTAT and 329 patients managed with openTTAT. No statistical differences were found between patient groups in mean age (41.3 vs 38.8years, P<.10), injury severity score (39.8 vs 36.0, P<.10), or technical success rates of the procedure (96.5% vs 98.5%, P = .58). In contrast, mortality was significantly lower in the endoTTAT group (7.6% vs 15.2%, P = .0076) as were rates of paraplegia (0% vs 5.6%, P<.0001) and stroke (0.85% vs 5.3%, P = .0028). The most common procedure-related complications for each technique were iliac artery injury during endoTTAT and recurrent laryngeal nerve injury after openTTAT.
CONCLUSIONS: To our knowledge, no large multicenter prospective randomized trial comparing endoTTAT and openTTAT has been published in the literature. This meta-analysis of pooled data serves as a surrogate, demonstrating a significant reduction in mortality, paraplegia, and stroke rates in patients who undergo endoTTAT; however, the long-term durability of endoTTAT remains in question.
AD
Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
PMID
8
TI
Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.
AU
Xenos ES, Minion DJ, Davenport DL, Hamdallah O, Abedi NN, Sorial EE, Endean ED
SO
Eur J Cardiothorac Surg. 2009 Feb;35(2):282-6. Epub 2008 Dec 10.
 
Rupture of thoracic aneurysm, acute type B dissection, blunt thoracic trauma, and penetrating aortic ulcer can present with a similar clinical profile of thoracic aortic rupture. We report a meta-analysis of comparative studies evaluating endoluminal graft versus open repair of these lesions as well as the early experience from our institution. We searched the following databases for reports of endovascular versus open repair of acute descending thoracic aortic rupture: Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. We used the random-effects model to calculate the odds ratio (OR) and 95% confidence intervals (CI) for mortality, paraplegia/paraparesis and stroke rates. Also, the medical records of the patients treated in our institution with this technique from 2000 to 2008 were reviewed. Demographics, comorbidities and operative procedure information were retrieved. Outcomes examined were mortality, paraplegia and stroke. Meta-analysis indicates that endoluminal graft repair is accompanied by lower procedure related mortality (OR 0.46, 95% CI 0.26-0.78, p=0.005) and paraplegia rates (OR 0.23, 95% CI 0.08-0.65, p=0.005), as compared to open repair. There was no difference in stroke rate between the two methods (OR 0.86,95% CI 0.26-2.8, p=0.8). We have treated 13 patients with endoluminal stent-grafts. No conversion to open repair was necessary. Stroke rate was 15%, no patient died as a result of the stent-graft placement, one patient died as a result of massive head injury (overall 30-day mortality: 7.5%). There were no spinal cord ischemic complications. Our experience and meta-analysis indicate that thoracic endograft repair has low mortality and spinal cord complication rates for treatment of acute thoracic aortic rupture. If this method proves to be durable, it could replace open repair as the treatment of choice for these critically ill patients.
AD
University of Kentucky Medical Center, Department of Surgery, Lexington, KY, USA.
PMID
9
TI
Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review.
AU
Hoffer EK, Forauer AR, Silas AM, Gemery JM
SO
J Vasc Interv Radiol. 2008 Aug;19(8):1153-64. Epub 2008 Jun 27.
 
PURPOSE: To evaluate the available data on stent-graft repair of acute blunt traumatic thoracic aortic injury with regard to safety and efficacy compared with conventional open surgical repair.
MATERIALS AND METHODS: The literature on endovascular repair of acute traumatic aortic injury since 1990 was systematically reviewed. Metaanalysis of publications with open and stent-graft repair cohorts was performed to evaluate whether there was a difference in treatment effect with regard to mortality and paraplegia. Case series were included to obtain an adequate population to assess the incidence of stent-graft procedure-related complications.
RESULTS: There were no prospective randomized studies. Nineteen publications that compared the outcomes of 262 endograft repairs and 376 open surgical repairs were identified. The odds ratio for mortality after endovascular versus open repair was 0.43 (95% CI, 0.26-0.70; P = .001). The odds ratio for paraplegia after endovascular versus open repair was 0.30 (95% CI, 0.12-0.76; P = .01). In the pooled group of 667 endovascular repair survivors from 50 reports, the incidence of early endoleak was 4.2%, and late endoleak occurred in 0.9%. Stroke or transient ischemic attack was reported in 1.2%. Access site complications that required intervention occurred in 4.1%.
CONCLUSIONS: The available cohort and case series data support stent-graft repair as a highly successful technique that may reduce mortality and paraplegia rates by half compared with open surgery. These data support endograft repair as first-line therapy for blunt thoracic aortic trauma.
AD
Dartmouth Medical School and the Department of Radiology, Section of Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA. eric.k.hoffer@hitchcock.org
PMID
10
TI
A meta-analysis of comparative studies of endovascular versus open repair for blunt thoracic aortic injury.
AU
Takagi H, Kawai N, Umemoto T
SO
J Thorac Cardiovasc Surg. 2008 Jun;135(6):1392-4. Epub 2008 Apr 21.
 
AD
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan. kfgth973@ybb.ne.jp
PMID
11
TI
Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm.
AU
Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE, Muhs BE
SO
J Vasc Surg. 2010 Apr;51(4):1026-32, 1032.e1-1032.e2.
 
INTRODUCTION: Ruptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA.
METHODS: We systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair.
RESULTS: Original data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 +/- 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P<.05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 +/- 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%.
CONCLUSION: Endovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up.
AD
Department of Surgery and Radiology, Sections of Vascular Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, Conn 06510, USA.
PMID
12
TI
Endovascular stenting versus open surgery for thoracic aortic disease: systematic review and meta-analysis of perioperative results.
AU
Walsh SR, Tang TY, Sadat U, Naik J, Gaunt ME, Boyle JR, Hayes PD, Varty K
SO
J Vasc Surg. 2008;47(5):1094. Epub 2008 Feb 1.
 
BACKGROUND: Endovascular stenting has emerged as an alternative to open repair in patients requiring surgery for thoracic aortic pathology. A number of comparative series have been published but, to date, there has been no meta-analysis comparing outcomes following stenting as opposed to open surgery.
METHODS: Electronic abstract databases and conference proceedings were searched to identify relevant series. Pooled odds ratios were calculated using random effects models for perioperative mortality, neurological injury, and major reintervention.
RESULTS: The search identified 17 eligible series, totaling 1109 patients (538 stenting). Stenting was associated with a significant reduction in mortality (pooled odds ratio 0.36; 95% CI 0.228-0.578; P<.0001) and major neurological injury (pooled odds ratio 0.39; 95% CI 0.25-0.62; P = .0001). There was no difference in the major reintervention rate (pooled odds ratio 0.91; 95% CI 0.610-1.619). There was a reduction in hospital and critical care stay although there was evidence of heterogeneity andbias with respect to these outcomes. Subgroup analyses suggested that endovascular repair reduced mortality (pooled odds ratio 0.25; 95% CI 0.09-0.66) and neurological morbidity (pooled odds ratio 0.28; 95% CI 0.13-0.61) in stable patients undergoing repair of thoracic aortic aneurysms. There was no effect on mortality in patients with thoracic aortic trauma but neurological injury was reduced (pooled odds ratio 0.17; 95% CI 0.03-1.03). Endovascular repair did not confer any apparent benefit over open surgery in patients with thoracic aortic rupture.
CONCLUSION: Endovascular thoracic aortic repair reduces perioperative mortality and neurological morbidity in patients with descending thoracic aortic aneurysms. There may be less benefit in other thoracic aortic conditions.
AD
Cambridge Vascular Unit, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom.
PMID
13
TI
Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma.
AU
Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA, Flynn W, Ney AL, Cone JB, Luchette FA, Wisner DH, Scholten DJ, Beaver BL, Conn AK, Coscia R, Hoyt DB, Morris JA Jr, Harviel JD, Peitzman AB, Bynoe RP, Diamond DL, Wall M, Gates JD, Asensio JA, Enderson BL
SO
J Trauma. 1997;42(3):374.
 
BACKGROUND: Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years.
METHODS: This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma.
RESULTS: There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of>or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia.
CONCLUSIONS: Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.
AD
University of Tennessee, Memphis, USA.
PMID
14
TI
Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study.
AU
Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, Hemmila MR, O'Connor JV, McKenney MO, Moore FO, London J, Singh MJ, Lineen E, Spaniolas K, Keel M, Sugrue M, Wahl WL, Hill J, Wall MJ, Moore EE, Margulies D, Malka V, Chan LS, American Association for the Surgery of Trauma Thoracic Aortic Injury Study Group
SO
J Trauma. 2008;64(3):561.
 
INTRODUCTION: The purpose of this American Association for the Surgery of Trauma multicenter study is to assess the early efficacy and safety of endovascular stent grafts (SGs) in traumatic thoracic aortic injuries and compare outcomes with the standard operative repair (OR).
PATIENTS: Prospective, multicenter study. Data for the following were collected: age, blood pressure, and Glasgow Coma Scale (GCS) at admission, type of aortic injury, injury severity score, abbreviate injury scale (AIS), transfusions, survival, ventilator days, complications, and intensive care unit and hospital days. The outcomes between the two groups (open repair or SG) were compared, adjusting for presence of critical extrathoracic trauma (head, abdomen, or extremity AIS>3), GCS score</=8, systolic blood pressure<90 mm Hg, and age>55 years. Separate multivariable analysis was performed, one for patients without and one for patients with associated critical extrathoracic injuries (head, abdomen, or extremity AIS>3), to compare the outcomes of the two therapeutic modalities adjusting for hypotension, GCS score</=8, and age>55 years.
RESULTS: One hundred ninety-three patients met the criteria for inclusion. Overall, 125 patients (64.9%) were selected for SG and 68 (35.2%) for OR. SG was selected in 71.6% of the 74 patients with major extrathoracic injuries and in 60.0% of the 115 patients with no major extrathoracic injuries. SG patients were significantly older than OR patients. Overall, 25 patients in the SG group (20.0%) developed 32 device-related complications. There were 18 endoleaks (14.4%), 6 of which needed open repair. Procedure-related paraplegia developed in 2.9% in the OR and 0.8% in the SG groups (p = 0.28). Multivariable analysis adjusting for severe extrathoracic injuries, hypotension, GCS, and age, showed that the SG group had a significantly lower mortality (adjusted odds ratio: 8.42; 95% CI: [2.76-25.69]; adjusted p value<0.001), and fewer blood transfusions (adjusted mean difference: 4.98; 95% CI: [0.14-9.82]; adjusted p value = 0.046) than the OR group. Among the 115 patients without major extrathoracic injuries, higher mortality and higher transfusion requirements were also found in the OR group (adjusted odds ratio for mortality: 13.08; 95% CI [2.53-67.53], adjusted p value = 0.002 and adjusted mean difference in transfusion units: 4.45; 95% CI [1.39-7.51]; adjusted p value = 0.004). Among the 74 patients with major extrathoracic injuries, significantly higher mortality and pneumonia rate were found in the OR group (adjusted p values 0.04 and 0.03, respectively). Multivariate analysis showed that centers with high volume of endovascular procedures had significantly fewer systemic complications (adjusted p value 0.001), fewer local complications (adjusted p value p = 0.033), and shorter hospital lengths of stay (adjusted p value 0.005)than low-volume centers.
CONCLUSIONS: Most surgeons select SG for traumatic thoracic aortic ruptures, irrespective of associated injuries, injury severity, and age. SG is associated with significantly lower mortality and fewer blood transfusions, but there is a considerable risk of serious device-related complications. There is a major and urgent need for improvement of the available endovascular devices.
AD
demetria@usc.edu
PMID