Abstract：
Society for Vascular Surgery (SVS) recommendations for managing intimal (grade 1) blunt thoracic aortic injuries (BTAIs) include observation and medical management. University of Washington (UW) revised criteria suggest that intimal injuries with ≥1 cm flap should be upgraded to a moderate injury and treatment be considered. We sought to evaluate and compare SVS and UW criteria for BTAI and determine how discordance in grading affected treatment and outcome.
We reviewed all patients admitted with BTAI from January 1, 2011, to March 31, 2022. Data included injury grading, demographics, and concomitant traumatic injuries. Images were reviewed to categorize the injury with both grading systems. Treatment and outcomes were analyzed for concordant and discordant groups.
Our cohort comprised 208 patients after excluding four who died upon arrival. The mean age was 45 ± 19 years, 69% were men, and the median injury severity score was 34 (interquartile range, 26-45). Strong agreement was observed between the grading systems (kappa = 0.88). All patients with concordant grade 1 injuries (n = 54) were observed. SVS grade 1/2 BTAIs were reclassified in 12 of 71 patients (16.9%). Two (28.6%) SVS grade 2 injuries were graded lower with the UW criteria; neither patient required immediate or delayed repair. Ten (15.6%) SVS grade 1 BTAIs were graded higher with UW criteria. Of these, six underwent repair (one for preoperative embolization), and four were observed without sequalae. Overall mortality was 7.7% with no difference for concordant or discordant grades (7.7% vs 8.3%; P = .99). No aneurysm-related mortalities were observed. Follow-up imaging was available for 94 survivors (49.0%) at a median of 193 days (interquartile range, 42-522 days). Two patients unrepaired at the index hospitalization (SVS grade 3/UW grade 2) underwent successful delayed repair. No patient observed for a minimal injury had BTAI progression or required treatment.
The UW grading system may upgrade or downgrade SVS grade 1 or 2 BTAI for as many as one in six injuries. Upgraded injuries should prompt consideration of repair if there is evidence of flap progression or thromboembolic complications. Downgraded injuries suggest that treatment may not be necessary; clinical expertise is key to determine optimal management in these patients.
We reviewed all patients admitted with BTAI from January 1, 2011, to March 31, 2022. Data included injury grading, demographics, and concomitant traumatic injuries. Images were reviewed to categorize the injury with both grading systems. Treatment and outcomes were analyzed for concordant and discordant groups.
Our cohort comprised 208 patients after excluding four who died upon arrival. The mean age was 45 ± 19 years, 69% were men, and the median injury severity score was 34 (interquartile range, 26-45). Strong agreement was observed between the grading systems (kappa = 0.88). All patients with concordant grade 1 injuries (n = 54) were observed. SVS grade 1/2 BTAIs were reclassified in 12 of 71 patients (16.9%). Two (28.6%) SVS grade 2 injuries were graded lower with the UW criteria; neither patient required immediate or delayed repair. Ten (15.6%) SVS grade 1 BTAIs were graded higher with UW criteria. Of these, six underwent repair (one for preoperative embolization), and four were observed without sequalae. Overall mortality was 7.7% with no difference for concordant or discordant grades (7.7% vs 8.3%; P = .99). No aneurysm-related mortalities were observed. Follow-up imaging was available for 94 survivors (49.0%) at a median of 193 days (interquartile range, 42-522 days). Two patients unrepaired at the index hospitalization (SVS grade 3/UW grade 2) underwent successful delayed repair. No patient observed for a minimal injury had BTAI progression or required treatment.
The UW grading system may upgrade or downgrade SVS grade 1 or 2 BTAI for as many as one in six injuries. Upgraded injuries should prompt consideration of repair if there is evidence of flap progression or thromboembolic complications. Downgraded injuries suggest that treatment may not be necessary; clinical expertise is key to determine optimal management in these patients.
摘要：
目的：血管外科学会（SVS）治疗内膜（1级）闭合性胸主动脉损伤（BTAI）的建议包括观察和医疗管理。华盛顿大学（UW）修订的标准建议，皮瓣≥1cm的内膜损伤应升级为中度损伤，并考虑治疗。我们试图评估和比较BTAI的SVS和UW标准，并确定分级不一致如何影响治疗和结果。
方法：我们回顾了2011年1月1日至2022年3月31日收治的所有BTAI患者。数据包括损伤分级，人口统计学和伴随的创伤性损伤。检查图像以使用两种分级系统对损伤进行分类。分析一致和不一致组的治疗和结果。
结果：我们的队列包括208名患者，排除了4名因抵达而死亡的患者。平均年龄为45±19岁，69%是男性,中位损伤严重程度评分（ISS）为34（IQR26-45）。在分级系统之间观察到强烈的一致性(kappa=0.88)。观察到所有合并1级损伤的患者（n=54）。SVS1/2级BTAI在12/71（16.9%）中重新分类。根据UW标准，两个（28.6％）SVS2级损伤的等级较低；两个患者都不需要立即或延迟修复。根据UW标准，10名(15.6%)SVS1级BTAI被评为更高的等级。其中,6例接受了修复（1例用于术前栓塞），4例没有后遗症。总死亡率为7.7％，一致或不一致等级没有差异（7.7％与8.3%,p=.99）。未观察到与动脉瘤相关的死亡率。94（49.0％）的幸存者可进行随访成像，中位时间为193（IQR42-522）天。两名在住院期间未修复的患者（SVS3级/UW2级）接受了成功的延迟修复。没有观察到最小损伤的患者有BTAI进展或需要治疗。
结论：对于多达六分之一的伤害，UW分级系统可能会升级或降级SVS1级或2级BTAI。如果有皮瓣进展或血栓栓塞并发症的证据，则升级的损伤应迅速考虑修复。降级的损伤表明可能不需要治疗；临床专业知识是确定这些患者最佳治疗的关键。
方法：我们回顾了2011年1月1日至2022年3月31日收治的所有BTAI患者。数据包括损伤分级，人口统计学和伴随的创伤性损伤。检查图像以使用两种分级系统对损伤进行分类。分析一致和不一致组的治疗和结果。
结果：我们的队列包括208名患者，排除了4名因抵达而死亡的患者。平均年龄为45±19岁，69%是男性,中位损伤严重程度评分（ISS）为34（IQR26-45）。在分级系统之间观察到强烈的一致性(kappa=0.88)。观察到所有合并1级损伤的患者（n=54）。SVS1/2级BTAI在12/71（16.9%）中重新分类。根据UW标准，两个（28.6％）SVS2级损伤的等级较低；两个患者都不需要立即或延迟修复。根据UW标准，10名(15.6%)SVS1级BTAI被评为更高的等级。其中,6例接受了修复（1例用于术前栓塞），4例没有后遗症。总死亡率为7.7％，一致或不一致等级没有差异（7.7％与8.3%,p=.99）。未观察到与动脉瘤相关的死亡率。94（49.0％）的幸存者可进行随访成像，中位时间为193（IQR42-522）天。两名在住院期间未修复的患者（SVS3级/UW2级）接受了成功的延迟修复。没有观察到最小损伤的患者有BTAI进展或需要治疗。
结论：对于多达六分之一的伤害，UW分级系统可能会升级或降级SVS1级或2级BTAI。如果有皮瓣进展或血栓栓塞并发症的证据，则升级的损伤应迅速考虑修复。降级的损伤表明可能不需要治疗；临床专业知识是确定这些患者最佳治疗的关键。
