Abstract：
OBJECTIVE: Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI.
METHODS: Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes.
RESULTS: Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission.
CONCLUSIONS: Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.
METHODS: Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes.
RESULTS: Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission.
CONCLUSIONS: Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.
摘要：
目的：目前社会上关于胸主动脉腔内修复术（TEVAR）治疗钝性胸主动脉损伤（BTAI）时机的建议各不相同。先前的研究表明，TEVAR治疗BTAI后，选择性修复与较低的死亡率相关。然而,这些研究缺乏血管外科学会(SVS)主动脉损伤分级和TEVAR相关术后结局等数据.因此,我们使用了血管质量倡议注册,其中包括相关的解剖和结果数据，检查BTAI的紧急/紧急(≤24小时)和选择性TEVAR后的结果。
方法：纳入了2013年至2022年接受TEVAR治疗BTAI的患者，不包括SVS4级主动脉损伤的患者。我们包括了协变量，如年龄，性别,种族,传输状态,身体质量指数,术前血红蛋白,合并症,药物使用,SVS主动脉损伤分级,共存的伤害，格拉斯哥昏迷量表，和在回归模型中的先前主动脉手术，以计算分配给紧急/紧急或选择性TEVAR的倾向评分。使用反向概率加权逻辑回归和Cox回归评估围手术期结果和5年死亡率。还调整了左锁骨下动脉血运重建/闭塞以及中心和医生的年度容量。
结果：在1016例患者中，102例（10%）接受了选择性TEVAR。接受选择性修复的患者更有可能进行左锁骨下动脉血运重建（31％vs7.5％；P<.001），并接受术中肝素（94％vs82％；P=.002）。在逆概率加权之后，TEVAR时机与围手术期死亡率之间没有关联(选择性与紧急/紧急:3.9%与6.6%;比值比[OR],1.1；95%置信区间[CI]，0.27-4.7；P=.90）和5年死亡率（5.8％vs12％；危险比[HR]，0.95；95%CI，0.21-4.3；P>.9）。与紧急/紧急TEVAR相比，选择性修复与术后卒中降低相关(1.0%vs2.1%；调整后的OR[aOR]，0.12；95%CI，0.02-0.94；P=0.044），即使在调整术中肝素使用后(aOR，0.12；95%CI，0.02-0.92；P=.042）。选择性TEVAR也与术后立即拔管失败的较低几率相关(39%vs65%;aOR,0.18；95%CI，0.09-0.35；P<.001）和术后肺炎（4.9%vs11%；aOR，0.34；95%CI，0.13-0.91；P=0.031），但任何术后并发症作为复合结局和初次入院期间的再干预的几率相当。
结论：接受选择性TEVAR的BTAI患者更有可能接受术中肝素治疗。择期和紧急/紧急TEVAR组的围手术期死亡率和5年死亡率相似。术后,选择性TEVAR与较低缺血性卒中相关,肺部并发症,和长期住院。社会指南的未来修改应纳入当前支持将TEVAR用于BTAI的证据。BTAI患者TEVAR的最佳时机及其决定因素应成为未来研究的主题，以促进个性化决策。
方法：纳入了2013年至2022年接受TEVAR治疗BTAI的患者，不包括SVS4级主动脉损伤的患者。我们包括了协变量，如年龄，性别,种族,传输状态,身体质量指数,术前血红蛋白,合并症,药物使用,SVS主动脉损伤分级,共存的伤害，格拉斯哥昏迷量表，和在回归模型中的先前主动脉手术，以计算分配给紧急/紧急或选择性TEVAR的倾向评分。使用反向概率加权逻辑回归和Cox回归评估围手术期结果和5年死亡率。还调整了左锁骨下动脉血运重建/闭塞以及中心和医生的年度容量。
结果：在1016例患者中，102例（10%）接受了选择性TEVAR。接受选择性修复的患者更有可能进行左锁骨下动脉血运重建（31％vs7.5％；P<.001），并接受术中肝素（94％vs82％；P=.002）。在逆概率加权之后，TEVAR时机与围手术期死亡率之间没有关联(选择性与紧急/紧急:3.9%与6.6%;比值比[OR],1.1；95%置信区间[CI]，0.27-4.7；P=.90）和5年死亡率（5.8％vs12％；危险比[HR]，0.95；95%CI，0.21-4.3；P>.9）。与紧急/紧急TEVAR相比，选择性修复与术后卒中降低相关(1.0%vs2.1%；调整后的OR[aOR]，0.12；95%CI，0.02-0.94；P=0.044），即使在调整术中肝素使用后(aOR，0.12；95%CI，0.02-0.92；P=.042）。选择性TEVAR也与术后立即拔管失败的较低几率相关(39%vs65%;aOR,0.18；95%CI，0.09-0.35；P<.001）和术后肺炎（4.9%vs11%；aOR，0.34；95%CI，0.13-0.91；P=0.031），但任何术后并发症作为复合结局和初次入院期间的再干预的几率相当。
结论：接受选择性TEVAR的BTAI患者更有可能接受术中肝素治疗。择期和紧急/紧急TEVAR组的围手术期死亡率和5年死亡率相似。术后,选择性TEVAR与较低缺血性卒中相关,肺部并发症,和长期住院。社会指南的未来修改应纳入当前支持将TEVAR用于BTAI的证据。BTAI患者TEVAR的最佳时机及其决定因素应成为未来研究的主题，以促进个性化决策。
