ABDUCENS PCC AMSC 2021

ABDUCENS ACADEMIC BUNDLE OF CREATIONS

PCC AMSC 2021 BY AMSA-UNHAS

SCIENTIFIC

POSTER

DISTRICT WINNER ThoracicEndovascularAortic Repair (TEVAR) Reduces Mortality Rate in Blunt Thoracic Aortic Injury (BTAI) Patients: A Systematic Review

Stevens Wijaya; Ennia Yuniarti Br Bancin; Andi Hanna Shelinda Silva; Yason Nikolaus Liyadi

Thoracic EndovascularAortic Repair (TEVAR) Reduces Mortality Rate in Blunt Thoracic Aortic Injury (BTAI) Patients: A SystematicReview Stevens Wijaya; Ennia Yuniarti Br Bancin; Andi Hanna Shelinda Silva; Yason Nikolaus Liyadi Hasanuddin University, Makassar, South Sulawesi ABSTRACT Introduction: Blunt thoracic aortic injury (BTAI) is a tear in the aorta as a result of a combination of shear and stretch forces, rapid deceleration, increased intravascular pressure and compression of the aorta between the anterior chest wall and vertebrae. Although the incidence of BTAI is less than 1%, this injury is the second leading cause of death in blunt trauma. The most common mechanism of BTAI involves motor vehicle collisions (MVCs). About 81% cases of BTAI are caused by Motor vehicle accidents. Up to 80% of patients presenting with BTAI die before hospitalization, and those who survive often present with multiple associated injuries, including cardiac lesions, rib fractures, hemothoraces, and intra-abdominal injuries(1).

In 2014, it was reported that approximately 28,000 fatalities due to accidents on the streets and roadways in Indonesia and the fatality rate from traffic accidents was about 12 per 100,000 population. It is estimated that in 2020, traffic fatality in Indonesia will reach 40,000 per year.

This is very high compared to the neighboring countries like Singapore (4.8) and Australia (5.2).

These numbers show that traffic accidents in Indonesia are extremely high.

Over 60% of blunt aortic injuries occur at the aortic isthmus, where the relatively fixed descending aorta meets the more mobile aortic arc. Therefore, this junction bears considerable strain on sudden deceleration. Other segments of the aorta, however, may also be involved.

These include the ascending aorta (8–27%), aortic arch (8–18%), distal descending aorta (11– 21%), and abdominal aorta (2).

Nowadays, the most commonly performed managemen of BTAI is endovascular aortic repair (TEVAR) . The American Association for the Surgery of Trauma (AAST) has classified thoracic vascular injuries based on the type of artery and the extent of arterial circumference involved.

TEVAR has emerged as the dominant therapy for BTAI. Although the SVS clinical practice guidelines recommend urgent (<24 h) repair, some studies suggest that delayed therapy is well

tolerated and may lead to improved outcomes. In this review we aim to evaluate the hospital managements of BTAI in reducing the mortality rate in BTAI patients (1).

Objective: To evaluate hospital managements

of Blunt Traumatic Aortic Injury cases in

reducing the mortality rate in patients diagnosed with BTAI. Methods: The methods used in this study are systematic review and meta-analysis, conducted in “PubMed”, “ScienceDirect”, and “ProQuest” using the keywords “Blunt Trauma” and “Aortic Injury”, and written in English.

Results: The diagnosis of BTAI starts with a thorough history and physical examination. The initial evaluation conforms to the Advanced Trauma Life Support guidelines. Patients may present in shock or with normal hemodynamics. Similarly, patients may report chest pain radiating to the back or remain asymptomatic. Important physical examination findings include distended neck veins, absent or muffled heart sounds, tracheal deviation, subcutaneous emphysema, chest wall instability or ecchymoses, abnormal breath sounds, and diminished peripheral pulses (1).

Imaging plays a central role in the diagnosis of BTAI. The initial imaging modality is a chest radiograph. Suggestive radiographic findings include a widened/abnormal mediastinum left pleural effusion, first and second rib fractures, tracheal deviation, a depressed left bronchus, an indistinct aortic knob, or apical capping. If there is clinical suspicion for BTAI, a computed tomographic angiogram (CTA) of the chest is necessary. Although for nearly four decades aortography/angiography was considered the gold standard for diagnosis of blunt aortic injury, CTA is considered the diagnostic test of choice in the modern era. If CTA findings are equivocal, intravascular ultrasound (IVUS) can be a helpful adjunct. Finally, angiography is a potential diagnostic modality but, with the advent of CTA, has been relegated from a screening to a mainly therapeutic role. In addition to faster and more accurate diagnosis, advances in modern imaging also provided a more detailed analysis of aortic lesions and thus paved the way for improved staging and treatment (3).

The current standard of care for grading BTAI was proposed in 2009 and has been adopted by the Society for Vascular Surgery clinical practice guidelines for the management of BTAI. Injuries are assigned one of 4 grades based on CTA imaging: (4)

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Grade 1: Intimale tear

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Grade 2: Intramural hematoma

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Grade 3: Pseudoaneurysm

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Grade 4: Rupture

The treatment of BTAI starts with adequate blood pressure control. Depending on the grade of the injury, this intervention serves as either a definitive or a temporizing measure. On the basis of the Society for Vascular Surgery (SVS) clinical practice guidelines, expectant management with effective blood pressure control is sufficient for grade I lesions, as the majority of these lesions heal spontaneously. Medical management with anti-impulse therapy is the initial and, for some patients, definitive intervention. For grade II–IV lesions, however, the SVS clinical practice guidelines recommend urgent TEVAR (1).

We acquired clinical case reports on TEVAR and open repair management of Aortic aneurysm caused by Blunt Thoracic Aortic Injury, based on the study data performed by (5): a. Mortality risk Eighteen studies including 22,702 patients reported 30-day mortality. TEVAR reduced the risk of 30-day mortality (OR, 0.56; 95% CI, 0.4-0.74). Subgroup analysis was done to compare 30-day mortality risk between intact (19,985 patients) and ruptured (2282 patients) aneurysms. In each subgroup, TEVAR reduced the risk of 30-day mortality in intact aneurysms (nine studies; OR, 0.6; 95% CI, 0.36-0.99; I 2 ¼ 77%) and in ruptured aneurysms (five studies; OR, 0.58; 95% CI, 0.38-0.88; I 2 ¼ 65%). Only one study compared 30-day mortality20 for patients with supradiaphragmatic TAAAs. The difference between the TEVAR and open repair groups was not statistically significant (OR, 0.55; 95% CI, 0.181.66). b. Paraplegia risk Six studies including 771 patients reported 30-day paraplegia or spinal cord ischemia.

TEVAR reduced paraplegia or spinal cord ischemia (OR, 0.35; 95% CI, 0.2-0.61). c. Stroke risk Eight studies including 41,401 patients reported 30-day stroke rates. The reduction in risk with TEVAR was not statistically significant (OR, 0.89; 95% CI, 0.76-1.03). d. Pulmonary complication risk

Four studies including 18,996 patients reported 30-day pulmonary complications. TEVAR was associated with a reduction in risk (OR, 0.41; 95% CI, 0.37-0.46) e. Length of Hospital and ICU stay Four studies including 346 patients reported ICU length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.89 days; 95% CI, -9.65 to -2.12).

Six studies including 1331 patients reported hospital length of stay. TEVAR was associated with shorter stay (pooled mean difference, -5.17 days; 95% CI, -7.77 to -2.57).

Alternatively, full cardiopulmonary bypass via femoral cannulation can be used. Although contemporary outcomes of surgical repair have improved, the overall and aortic-related mortalities remain relatively high (19.7%). Citing lower risks of death and spinal cord ischemia, the SVS clinical practice guidelines recommend TEVAR over open repair for all age groups with suitable anatomy. TEVAR was used in 76.4% of the 382 BTAI patients. The majority (50.3%) of injuries were grade III lesions, followed by grade I (24.6%), grade II (17.8%), and grade IV (7.3%) lesions. The overall in-hospital mortality was 18.8%, and the aortic-related mortality was 6.5%. TEVAR also reduce Mortality in patients admitted with traumatic thoracic aortic injuries declined from 24.5% to 13.3% (1).

Conclusion: Patients of aortic aneurysm complication in Blunt Thoracic Aortic Injury who undergo TEVAR have reduced risk of mortality, paraplegia, and pulmonary complications within 30 days of intervention compared with patients who undergo open repair. Patients undergoing TEVAR also had a shorter hospital and ICU length of stay. Therefore, the procedure of TEVAR for the treatment of Blunt thoracic aortic injury (BTAI) patients is

has been

recommended for most cases. TEVAR was the only protective variable against aortic-related mortality. Advances in imaging, development of a contemporary classification system, and the advent of TEVAR have all decreased the risk of mortality in Blunt thoracic aortic injury (BTAI) Keyword: Blunt Thoracic Aortic Injury, blunt Aortic injury, blunt trauma, management, Thoracic Endovascular Aortic Repair (Tevar) , bypass for repair of Aortic injury.

BIBLIOGRAPHY 1.

Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis [Internet]. 2019 Mar 25 [cited 2021 Apr 3];12(1):1–5. Available from: /pmc/articles/PMC6434345/

2.

Teixeira PGR, Inaba K, Barmparas G, Georgiou C, Toms C, Noguchi TT, et al. Blunt thoracic aortic injuries: An autopsy study. J Trauma - Inj Infect Crit Care [Internet]. 2011 Jan [cited 2021 Apr 3];70(1):197–202. Available from: https://pubmed.ncbi.nlm.nih.gov/21217494/

3.

Azizzadeh A, Valdes J, Miller CC, Nguyen LL, Estrera AL, Charlton-Ouw K, et al. The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury. J Vasc Surg [Internet]. 2011 Mar [cited 2021 Apr 3];53(3):608–14.

Available from: https://pubmed.ncbi.nlm.nih.gov/21129901/

4.

Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury Concepts and management [Internet]. Vol. 15, Journal of Cardiothoracic Surgery. BioMed Central Ltd.; 2020 [cited 2021 Apr 3]. p. 62. Available from: https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01101-6

5.

Alsawas M, Zaiem F, Larrea-Mantilla L, Almasri J, Erwin PJ, Upchurch GR, et al.

Effectiveness of surgical interventions for thoracic aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg [Internet]. 2017;66(4):1258-1268.e8. Available from: http://dx.doi.org/10.1016/j.jvs.2017.05.082