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Abstract：
Although the Society for Vascular Surgery (SVS) aortic injury grading system is used to depict the severity of injury in patients with blunt thoracic aortic injury, prior literature on its association with outcomes after thoracic endovascular aortic repair (TEVAR) is limited.
We identified patients undergoing TEVAR for BTAI within the VQI between 2013 and 2022. We stratified patients based on their SVS aortic injury grade (grade 1, intimal tear; grade 2, intramural hematoma; grade 3, pseudoaneurysm; and grade 4, transection or extravasation). We assessed perioperative outcomes and 5-year mortality using multivariable logistic and Cox regression analyses. Secondarily, we assessed the proportional trends in patients undergoing TEVAR based on SVS aortic injury grade over time.
Overall, 1311 patients were included (grade1, 8%; grade 2, 19%; grade 3, 57%; grade 4, 17%). Baseline characteristics were similar, except for a higher prevalence of renal dysfunction, severe chest injury (Abbreviated Injury Score >3), and lower Glasgow Coma Scale with increasing aortic injury grade (Ptrend < .05). Rates of perioperative mortality by aortic injury grade were as follows: grade 1, 6.6%; grade 2, 4.9%; grade 3, 7.2%; and grade 4, 14% (Ptrend = .003) and 5-year mortality rates were 11% for grade 1, 10% for grade 2, 11% for grade 3, and 19% for grade 4 (P = .004). Patients with grade 1 injury had a high rate of spinal cord ischemia (2.8% vs grade 2, 0.40% vs grade 3, 0.40% vs grade 4, 2.7%; P = .008). After risk adjustment, there was no association between aortic injury grade and perioperative mortality (grade 4 vs grade 1, odds ratio, 1.3; 95% confidence interval, 0.50-3.5; P = .65), or 5-year mortality (grade 4 vs grade 1, hazard ratio, 1.1; 95% confidence interval, 0.52-2.30; P = .82). Although there was a trend for decrease in the proportion of patients undergoing TEVAR with a grade 2 BTAI (22% to 14%; Ptrend = .084), the proportion for grade 1 injury remained unchanged over time (6.0% to 5.1%; Ptrend = .69).
After TEVAR for BTAI, there was higher perioperative and 5-year mortality in patients with grade 4 BTAI. However, after risk adjustment, there was no association between SVS aortic injury grade and perioperative and 5-year mortality in patients undergoing TEVAR for BTAI. More than 5% of patients with BTAI who underwent TEVAR had a grade 1 injury, with a concerning rate of spinal cord ischemia potentially attributable to TEVAR, and this proportion did not decrease over time. Further efforts should focus on enabling careful selection of patients with BTAI who will experience more benefit than harm from operative repair and preventing the inadvertent use of TEVAR in low-grade injuries.
We identified patients undergoing TEVAR for BTAI within the VQI between 2013 and 2022. We stratified patients based on their SVS aortic injury grade (grade 1, intimal tear; grade 2, intramural hematoma; grade 3, pseudoaneurysm; and grade 4, transection or extravasation). We assessed perioperative outcomes and 5-year mortality using multivariable logistic and Cox regression analyses. Secondarily, we assessed the proportional trends in patients undergoing TEVAR based on SVS aortic injury grade over time.
Overall, 1311 patients were included (grade1, 8%; grade 2, 19%; grade 3, 57%; grade 4, 17%). Baseline characteristics were similar, except for a higher prevalence of renal dysfunction, severe chest injury (Abbreviated Injury Score >3), and lower Glasgow Coma Scale with increasing aortic injury grade (Ptrend < .05). Rates of perioperative mortality by aortic injury grade were as follows: grade 1, 6.6%; grade 2, 4.9%; grade 3, 7.2%; and grade 4, 14% (Ptrend = .003) and 5-year mortality rates were 11% for grade 1, 10% for grade 2, 11% for grade 3, and 19% for grade 4 (P = .004). Patients with grade 1 injury had a high rate of spinal cord ischemia (2.8% vs grade 2, 0.40% vs grade 3, 0.40% vs grade 4, 2.7%; P = .008). After risk adjustment, there was no association between aortic injury grade and perioperative mortality (grade 4 vs grade 1, odds ratio, 1.3; 95% confidence interval, 0.50-3.5; P = .65), or 5-year mortality (grade 4 vs grade 1, hazard ratio, 1.1; 95% confidence interval, 0.52-2.30; P = .82). Although there was a trend for decrease in the proportion of patients undergoing TEVAR with a grade 2 BTAI (22% to 14%; Ptrend = .084), the proportion for grade 1 injury remained unchanged over time (6.0% to 5.1%; Ptrend = .69).
After TEVAR for BTAI, there was higher perioperative and 5-year mortality in patients with grade 4 BTAI. However, after risk adjustment, there was no association between SVS aortic injury grade and perioperative and 5-year mortality in patients undergoing TEVAR for BTAI. More than 5% of patients with BTAI who underwent TEVAR had a grade 1 injury, with a concerning rate of spinal cord ischemia potentially attributable to TEVAR, and this proportion did not decrease over time. Further efforts should focus on enabling careful selection of patients with BTAI who will experience more benefit than harm from operative repair and preventing the inadvertent use of TEVAR in low-grade injuries.
摘要：
目的：尽管血管外科学会（SVS）主动脉损伤分级系统用于描述钝性胸主动脉损伤（BTAI）患者的损伤严重程度，关于其与胸主动脉腔内修复术(TEVAR)后结局相关的现有文献有限.
方法：我们确定了2013-2022年期间在VQI内接受TEVAR治疗BTAI的患者。我们根据患者的SVS主动脉损伤等级（1级：内膜撕裂；2级：壁内血肿；3级：假性动脉瘤；4级：横切/外渗）对患者进行分层。我们使用多变量logistic和Cox回归分析评估围手术期结局和5年死亡率。其次，我们根据一段时间内SVS主动脉损伤分级评估了TEVAR患者的比例趋势.
结果：总体而言，纳入1,311例患者（等级1：8％；2级：19％；3级：57％；4级：17％）。基线特征相似，但肾功能不全的患病率较高。严重胸部损伤（缩写损伤评分>3），随着主动脉损伤分级的增加，GCS降低（p趋势<0.05）。按主动脉损伤等级划分的围手术期死亡率如下：1级：6.6％；2级：4.9％；3级：7.2％；4级：14％（p趋势=.003），5年死亡率为：1级：11％；2级：10％；3级：11％；4级：19％；（p=.004）。1级患者的脊髓缺血率高（2.8％vs2级：0.40％vs3级：0.40％vs4级：2.7％；p=.008）。风险调整后，主动脉损伤分级与围手术期死亡率之间没有关联(4级与1级：比值比（OR）：1.3[95CI：0.50-3.5]；p=.65），或5年死亡率（4级与1级，HR：1.1[95CI：0.52-2.3]；p=.82）。虽然2级BTAI的TEVAR患者比例有下降的趋势（22％至14％；p趋势=0.084），1级损伤的比例随着时间的推移保持不变（6.0％至5.1％；p趋势=0.69）结论：在BTAI的TEVAR之后，4级患者的围手术期和5年死亡率较高.然而,风险调整后，在接受TEVAR治疗BTAI的患者中,SVS主动脉损伤分级与围手术期和5年死亡率之间无相关性.超过5%的接受TEVAR的BTAI患者有1级损伤，脊髓缺血的发生率可能归因于TEVAR，这个比例并没有随着时间的推移而减少。进一步的努力应集中在仔细选择BTAI患者，这些患者将从手术修复中获得比伤害更多的益处，并防止在低度伤害中意外使用TEVAR。
方法：我们确定了2013-2022年期间在VQI内接受TEVAR治疗BTAI的患者。我们根据患者的SVS主动脉损伤等级（1级：内膜撕裂；2级：壁内血肿；3级：假性动脉瘤；4级：横切/外渗）对患者进行分层。我们使用多变量logistic和Cox回归分析评估围手术期结局和5年死亡率。其次，我们根据一段时间内SVS主动脉损伤分级评估了TEVAR患者的比例趋势.
结果：总体而言，纳入1,311例患者（等级1：8％；2级：19％；3级：57％；4级：17％）。基线特征相似，但肾功能不全的患病率较高。严重胸部损伤（缩写损伤评分>3），随着主动脉损伤分级的增加，GCS降低（p趋势<0.05）。按主动脉损伤等级划分的围手术期死亡率如下：1级：6.6％；2级：4.9％；3级：7.2％；4级：14％（p趋势=.003），5年死亡率为：1级：11％；2级：10％；3级：11％；4级：19％；（p=.004）。1级患者的脊髓缺血率高（2.8％vs2级：0.40％vs3级：0.40％vs4级：2.7％；p=.008）。风险调整后，主动脉损伤分级与围手术期死亡率之间没有关联(4级与1级：比值比（OR）：1.3[95CI：0.50-3.5]；p=.65），或5年死亡率（4级与1级，HR：1.1[95CI：0.52-2.3]；p=.82）。虽然2级BTAI的TEVAR患者比例有下降的趋势（22％至14％；p趋势=0.084），1级损伤的比例随着时间的推移保持不变（6.0％至5.1％；p趋势=0.69）结论：在BTAI的TEVAR之后，4级患者的围手术期和5年死亡率较高.然而,风险调整后，在接受TEVAR治疗BTAI的患者中,SVS主动脉损伤分级与围手术期和5年死亡率之间无相关性.超过5%的接受TEVAR的BTAI患者有1级损伤，脊髓缺血的发生率可能归因于TEVAR，这个比例并没有随着时间的推移而减少。进一步的努力应集中在仔细选择BTAI患者，这些患者将从手术修复中获得比伤害更多的益处，并防止在低度伤害中意外使用TEVAR。
