Jason A. London

Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study.

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.

Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives.

BACKGROUND The diagnosis and management of blunt thoracic aortic injuries has undergone many significant changes over the last decade. The present study compares clinical practices and results between an earlier prospective multicenter study by the American Association for the Surgery of Trauma completed in 1997 (AAST1) and a new similar study completed in 2007 (AAST2). METHODS The AAST1 study included 274 patients from 50 participating centers over a period of 30 months. The AAST2 study included 193 patients from 18 centers, over a period of 26 months. The comparisons between the two studies included the method of definitive diagnosis of the aortic injury [computed tomography (CT) scan, aortography, transesophageal echocardiogram (TEE) or magnetic resonance imaging], the method of definitive aortic repair (open repair vs. endovascular repair, clamp and sew vs. bypass techniques), the time from injury to procedure (early vs. delayed repair), and outcomes (survival, procedure-related paraplegia, other complications). RESULTS There was a major shift of the method of definitive diagnosis of the aortic injury, from aortography in the AAST1 to CT scan in AAST2, and a nearly complete elimination of aortography and TEE in the AAST2 study. In the AAST2 study the diagnosis was made by CT scan in 93.3%, aortography in 8.3%, and TEE in 1.0% of patients when compared with 34.8%, 87.0%, and 11.9%, respectively, in the AAST1 study (p < 0.001). The mean time from injury to aortic repair increased from 16.5 hours in the AAST1 study to 54.6 hours in the AAST2 study (p < 0.001). In the AAST1 study, all patients were managed with open repair, whereas in the AAST2 study only 35.2% were managed with open repair and the remaining 64.8% were managed with endovascular stent-grafts. In the patients managed with open repair, the use of bypass techniques increased from 64.7% to 83.8%. The overall mortality, excluding patients in extremis, decreased significantly from 22.0% to 13.0% (p = 0.02). Also, the incidence of procedure-related paraplegia in patients with planned operation, decreased from 8.7% to 1.6% (p = 0.001). However, the incidence of early graft-related complications increased from 0.5% in the AAST1 to 18.4% in the AAST2 study. CONCLUSIONS Comparison between the two AAST studies in 1997 and 2007 showed a major shift in the diagnosis of the aortic injury, with the widespread use of CT scan and the almost complete elimination of aortography and TEE. The concept of delayed definitive repair has gained wide acceptance. Endovascular repair has replaced open repair to a great extent. These changes have resulted in a major reduction of mortality and procedure-related paraplegia but also a significant increase of early graft-related complications.

Blunt Traumatic Thoracic Aortic Injuries: Early or Delayed Repair—results of an American Association for the Surgery of Trauma Prospective Study

BACKGROUND The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair (< or = 24 hours) and delayed repair groups (> 24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate.

Priorities for Improving Hospital-based Trauma Care in an African City

BACKGROUND This study sought to identify potential cost-effective methods to improve trauma care in hospitals in the developing world. METHODS Injured patients admitted to an urban hospital in Ghana over a 1-year period were analyzed prospectively for mechanism of injury, mode of transport to the hospital, injury severity, region of principal injury, operations performed, and mortality. In addition, time from injury until arrival at the hospital and time from arrival at the hospital until emergency surgery were evaluated. RESULTS Mortality was 9.4%. Most deaths (65%) occurred within 24 hours of admission. Sixty percent of emergency operations were performed over 6 hours after arrival. Tube thoracostomy was performed on only 13 patients (0.6%). Only 58% of patients received intravenous crystalloid and only 3.6% received 1 or more units of blood. CONCLUSION We identified several specific interventions as potential low-cost measures to improve hospital-based trauma care in this setting, including shorter times to emergency surgery and improvements in initial resuscitation. In addition to addressing each of these aspects of trauma care individually, quality improvement programs may represent a feasible and sustainable method to improve trauma care in hospitals in the developing world.

Evaluation of Short-term and Long-term Complications after Emergent Internal Iliac Artery Embolization in Patients with Pelvic Trauma

PURPOSE To assess the incidence of long- and short-term complications following internal iliac artery (IIA) embolization after blunt pelvic trauma. MATERIALS AND METHODS One hundred trauma patients with pelvic fractures underwent pelvic angiography from 1994 through 2006. Sixty-seven patients underwent IIA embolization. These patients were retrospectively identified for medical record review. Short- and long-term complications were defined as those occurring at less than or greater than 30 days, respectively. Complications and outcomes were assessed through chart review and, when possible, a standardized questionnaire. Patients who underwent IIA embolization were compared with matched control patients with blunt pelvic trauma who did not undergo pelvic arteriography. Individuals were matched by age, sex, year of admission, and injury scores. RESULTS There were no significant differences in skin necrosis, sloughing, pelvic perineal infection, or nerve injury between embolized and nonembolized patients within 30 days. There was no significant difference in claudication, skin ulceration, or regional pain at a mean of 18.4 months follow-up. In the long term, buttock, thigh, and perineal paresthesia occur at a significantly higher rate in embolized patients. Skin sloughing in the embolized patient group is an important but rare complication. CONCLUSIONS IIA embolization is an important means of controlling pelvic arterial hemorrhage. There is no significant increase in the risk of most evaluated long- and short-term complications in trauma patients who underwent IIA embolization versus those who did not. However, IIA embolization is associated with a marginally significantly increased rate of buttock, thigh, or perineal paresthesia.

Is there a relationship between trauma center volume and mortality

BACKGROUND The guidelines for Level I trauma center verification require 1,200 admissions per year. Several studies looking at the relationship between hospital volume and outcomes after injury have reached conflicting conclusions. The goal of our study was to examine the relationship between patient volume and outcomes (mortality and length of hospital stay) in Californias trauma centers. METHODS Data for patients >or= 18 years old admitted after injury (n = 98,245) to a Level I or II trauma center (n = 38) in 1998 and 1999 were obtained from the Patient Discharge Data of the State of California. Hospital volume was derived from the annual number of admissions per center, and covariates including age, sex, mechanism of injury, Injury Severity Score, and trauma center designation were analyzed. RESULTS Hospital volume was not a significant predictor of death or length of hospital stay. More severely injured patients appeared to have worse outcomes at the highest volume centers. CONCLUSION In our study, hospital volume was not a good proxy for outcome. Low-volume centers appeared to have outcomes that were comparable to centers with higher volumes. Perhaps institutional outcomes rather than volumes should be used as a criterion for trauma center verification.

Safety of Early Mobilization of Patients With Blunt Solid Organ Injuries

BACKGROUND Many surgeons believe that early mobilization of patients with blunt solid organ injuries increases the risk of delayed hemorrhage. OBJECTIVE To determine whether there is an association between the day of mobilization and rates of delayed hemorrhage from blunt solid organ injuries. DESIGN Retrospective cohort study. Univariate and multivariate analyses were performed to determine the association of mobilization with delayed hemorrhage of a solid organ requiring laparotomy. SETTING Level I trauma center. PATIENTS Adults with blunt renal, hepatic, or splenic injuries were identified from a trauma registry. MAIN OUTCOME MEASURES Medical records were used to determine the day of mobilization and to identify patients with delayed hemorrhage requiring laparotomy. RESULTS Four hundred fifty-four patients with blunt solid organ injuries were admitted to the hospital for nonoperative management. Failure rates of nonoperative management were 4.0%, 1.0%, and 7.1% for renal, hepatic, and splenic injuries, respectively. No patients with renal or hepatic injuries failed secondary to delayed hemorrhage. Ten patients (5.5%) with splenic injuries failed secondary to delayed hemorrhage. Eighty-four percent of patients with renal injuries, 80% with hepatic injuries, and 77% with splenic injuries were mobilized within 72 hours of admission. Day of mobilization was not associated with delayed splenic rupture in multivariate analysis (odds ratio, 0.97; 95% confidence interval, 0.90-1.05). CONCLUSIONS The timing of mobilization of patients with blunt solid organ injuries does not seem to contribute to delayed hemorrhage requiring laparotomy. Protocols incorporating periods of strict bed rest are unnecessary.

Analysis of admissions and outcomes in verified and nonverified burn centers.

The American Burn Association instituted a burn center verification process to ensure optimal care for patients with burn injury. Limited data exist regarding differences in admissions and outcomes between verified (VC) and nonverified burn centers (NVC). The study purpose was to compare demographics, treatment, and outcomes of VC and NVC. The five VC were compared with the 12 NVC using data from California’s discharge database for the year 2003. A total of 2867 patients were admitted to a burn center, 1645 to NVC (132/center), and 1222 (244/center) to VC. NVC admitted 1496 (91%) of their patients from local area and 118 (7%) from other acute care hospitals; in contrast, 948 (78%) of VC patients were local and 253 (21%) were transfers from other acute care hospitals. VCs admitted twice as many burns ≥80% total body surface area as NVC. VCs admitted more patients with face burns (18% VC vs 14% NVC, P < .001), had more patients on mechanical ventilation (12.4% VC vs 9.9% NVC P < .04), and performed fewer operations (61% VC vs 66% NVC, P < .006). Mortality rate was 3% in NVC and 4% in VC. During the study period verified centers in California admitted more patients per center and treated more severely injured patients than nonverified centers. Despite these differences, VC had mortality rates comparable to their nonverified counterparts. These findings support the need for additional studies evaluating the impact of verification on burn care.

Methamphetamine Use is Associated With Increased Hospital Resource Consumption Among Minimally Injured Trauma Patients

BACKGROUND The clinical effects of methamphetamines (MA) may complicate medical management, potentially increasing resource utilization and hospital costs out of proportion to the patients severity of injury. We hypothesize that minimally injured (MI) patients testing positive for MA consume more resources than patients testing negative for MA. METHODS Adult trauma patients were identified from 4 years of registry data, which was linked to cost data from our centers financial department. Patients were classified as MI (Injury Severity Score <9) or severely injured (Injury Severity Score >9). Primary outcome was total direct costs for the inpatient hospital stay. Secondary outcomes included direct costs by cost center, contribution margin, and hospital length of stay. RESULTS Sixty-five percent (n = 6,193) of the 10,663 adult patients during the study period were admitted with MI. Nine percent (n = 557) of those tested were positive for MA. Total direct costs were higher in MI MA patients compared to nonusers (

Lack of Insurance is Associated With Increased Risk for Hernia Complications.

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