Does Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury Increase the Probability of Delayed Intra-abdominal Hemorrhage in Patients With Concomitant Blunt Abdominal Trauma?

Abstract

Purpose:

Most blunt thoracic aortic injuries (BTAIs) may be treated using thoracic endovascular aortic repair (TEVAR), and most blunt abdominal traumas (BATs) are managed conservatively. We hypothesized that severe trauma that needs TEVAR may increase the risk of delayed intra-abdominal hemorrhage in patients with concomitant BTAI and BAT because of the potential hemorrhagic shock, disseminated intravascular coagulopathy, blood loss, consequent need for blood transfusion, and procedure-associated heparinization.

Materials and Methods:

From 2015 to 2019, blunt trauma patients with concomitant severe chest trauma and abdominal trauma who could be managed conservatively were studied. The probability of delayed intra-abdominal hemorrhage was compared between patients with concomitant BTAI who received or did not undergo TEVAR. Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and multivariate logistic regression (MLR) were used to eliminate discrepancies between these 2 groups.

Results:

Among the 341 studied patients, there were 26 patients with BTAI, and 19 of them underwent TEVAR. Delayed intra-abdominal hemorrhage was observed in 4 patients (21.1%, 4/19) who underwent TEVAR. Both PSM and IPTW showed that patients who underwent TEVAR for concomitant BTAI had a greater delayed need for blood transfusions and a larger proportion of delayed intra-abdominal hemorrhage than patients who did not undergo the procedure. The MLR analysis showed that TEVAR for BTAI was an independent risk factor for delayed intra-abdominal hemorrhage (odds ratio: 10.534, 95%, p<0.001).

Conclusion:

An increased probability of delayed intra-abdominal hemorrhage in patients with BAT (who could be managed conservatively) was observed in patients who underwent TEVAR for concomitant BTAI.

Clinical Impact

More attention should be give in patients with high grade aortic injuries and concomitant abdominal trauma.

Keywords

EVAR blunt abdominal trauma blunt aortic injury delayed hemorrhage

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References

Smith

Chang

FC.

Traumatic rupture of the aorta: still a lethal injury. Am J Surg. 1986;152(6):660–663. doi:10.1016/0002-9610(86)90444-7.

Akhmerov

DuBose

Azizzadeh

Blunt thoracic aortic injury: current therapies, outcomes, and challenges. Ann Vasc Dis. 2019;12(1):1–5. doi:10.3400/avd.ra.18-00139.

Arthurs

Starnes

Sohn

, et al. Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the national trauma databank. J Vasc Surg. 2009;49(4):988–994. doi:10.1016/j.jvs.2008.11.052.

Neschis

Scalea

Flinn

, et al. Blunt aortic injury. N Engl J Med. 2008;359(16):1708–1716. doi:10.1056/NEJMra0706159.

Lawlor

Ott

Forbes

, et al. Endovascular management of traumatic thoracic aortic injuries. Can J Surg. 2005;48(4):293–297.

Scalea

Feliciano

DuBose

, et al. Blunt thoracic aortic injury: endovascular repair is now the standard. J Am Coll Surg. 2019;228(4):605–610. doi:10.1016/j.jamcollsurg.2018.12.022.

Wee

Syn

, et al. The endovascular repair of blunt traumatic thoracic aortic injury in Asia: a systematic review and meta-analysis. Vascular. 2019;27(2):213–223. doi:10.1177/1708538119828887.

Kenel-Pierre

Ramos Duran

Abi-Chaker

, et al. The role of heparin in endovascular repair of blunt thoracic aortic injury. J Vasc Surg. 2019;70(6):1809–1815. doi:10.1016/j.jvs.2019.01.065.

Lee

Matsumura

Mitchell

, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187–192. doi:10.1016/j.jvs.2010.08.027.

10.

Velmahos

Toutouzas

Radin

, et al. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138(8):844–851. doi:10.1001/archsurg.138.8.844.

11.

Makaloski

Widenka

Schönhoff

, et al. Efficacy and safety of heparinization before deployment of endograft for blunt traumatic aortic injury in severely injured patients. Ann Vasc Surg. 2021;75:341–348. doi:10.1016/j.avsg.2021.01.096.

12.

Quiroga

Levitt

Czerwonko

, et al. Management of moderate blunt thoracic aortic injuries in patients with intracranial hemorrhage. Ann Vasc Surg. 2021;73:15–21. doi:10.1016/j.avsg.2020.11.009.

13.

Stein

Scalea

TM.

Nonoperative management of spleen and liver injuries. J Intensive Care Med. 2006;21(5):296–304. doi:10.1177/0885066606290854.

14.

Schroeppel

Croce

MA.

Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care. 2007;13(4):399–404. doi:10.1097/MCC.0b013e32825a6a32.

15.

Hsieh

Cheng Tsai

Liang

, et al. Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy. World J Emerg Surg. 2014;9(1):51. doi:10.1186/1749-7922-9-51.

16.

Azizzadeh

Keyhani

Miller

III , et al. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009;49(6):1403–1408. doi:10.1016/j.jvs.2009.02.234.

17.

Austin

PC.

An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399–424. doi:10.1080/00273171.2011.568786.

18.

Austin

PC.

Statistical criteria for selecting the optimal number of untreated subjects matched to each treated subject when using many-to-one matching on the propensity score. Am J Epidemiol. 2010;172(9):1092–1097. doi:10.1093/aje/kwq224.

19.

Cottone

Anota

Bonnetain

, et al. Propensity score methods and regression adjustment for analysis of nonrandomized studies with health-related quality of life outcomes. Pharmacoepidemiol Drug Saf. 2019;28(5):690–699. doi:10.1002/pds.4756.

20.

Anderson

Jin

Grunkemeier

GL.

Understanding logistic regression analysis in clinical reports: an introduction. Ann Thorac Surg. 2003;75(3):753–757. doi:10.1016/s0003-4975(02)04683-0.

21.

Austin

PC.

Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083–3107. doi:10.1002/sim.3697.

22.

Raza

Abbas

Devi

, et al. Non operative management of abdominal trauma–a 10 years review. World J Emerg Surg. 2013;8:14. doi:10.1186/1749-7922-8-14.

23.

Baumann

Raja

, et al. Blunt traumatic aortic injury in the pan-scan era. Acad Emerg Med. 2020;27(4):291–296. doi:10.1111/acem.13900.

24.

Fabian

Richardson

Croce

, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma. 1997;42(3):374–380; discussion 380–383. doi:10.1097/00005373-199703000-00003.

25.

Duan

The pathophysiology and management of acute traumatic coagulopathy. Clin Appl Thromb Hemost. 2015;21(7):645–652. doi:10.1177/1076029613516190.

26.

Hayakawa

Pathophysiology of trauma-induced coagulopathy: disseminated intravascular coagulation with the fibrinolytic phenotype. J Intensive Care. 2017;5:14. doi:10.1186/s40560-016-0200-1.

27.

Mouawad

Paulisin

Hofmeister

, et al. Blunt thoracic aortic injury-concepts and management. J Cardiothorac Surg. 2020;15(1):62. doi:10.1186/s13019-020-01101-6.

28.

Yanar

Ertekin

Taviloglu

, et al. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma. 2008;64(4):943–948. doi:10.1097/TA.0b013e3180342023.

29.

Sandhu

Leonard

Perlick

, et al. Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries. J Vasc Surg. 2018;67(2):389–398. doi:10.1016/j.jvs.2017.07.111.

30.

Moore

Kornblith

, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers. 2021;7(1):30. doi:10.1038/s41572-021-00264-3.

31.

Santaniello

Miller

Croce

, et al. Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited. J Trauma. 2002;53(3):442–445; discussion 445. doi:10.1097/00005373-200209000-00008.

32.

George

Rothenberg

, et al. Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury. J Vasc Surg. 2021;74(1):71–78. doi:10.1016/j.jvs.2020.12.068.

33.

Doganer

Jongkind

Blankensteijn

, et al. A standardized bolus of 5 000 IU of heparin does not lead to adequate heparinization during non-cardiac arterial procedures. Ann Vasc Surg. 2021;71:280–287. doi:10.1016/j.avsg.2020.07.035.

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