RESUMO
OBJECTIVE: Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management. METHODS: We performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability. RESULTS: A total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography. CONCLUSIONS: Nonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.
Assuntos
Falso Aneurisma , Procedimentos Endovasculares , Traumatismos Torácicos , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Falso Aneurisma/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Hematoma , Humanos , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
Resumo O cenário atual do trauma por causas violentas tem apresentado um elevado número de casos. Entre eles, a lesão de aorta torácica por trauma penetrante é uma condição de elevada morbimortalidade que exige diagnóstico adequado e que, nos últimos anos, tem sido corrigida com procedimentos endovasculares. Essa modalidade de tratamento se mostra mais segura, com menor número de complicações em relação ao procedimento cirúrgico aberto. Após a realização da abordagem endovascular, há necessidade de acompanhamento contínuo, que visa monitorar as condições de saúde do paciente e corrigir possíveis complicações relacionadas ao procedimento. O objetivo deste artigo é relatar um caso de traumatismo penetrante de aorta torácica, tratado por via endovascular, visto que a literatura aborda predominantemente as lesões por trauma contuso.
Abstract In the current scenario, traumas with violent causes are responsible for large numbers of cases. Among these, thoracic aorta injury caused by penetrating trauma is a cause of elevated morbidity and mortality, demanding adequate diagnosis, and can now often be repaired using endovascular procedures. This treatment method has proven to be safer, with a lower rate of complications than open surgical procedures. After endovascular repair, it is necessary to conduct continuous monitoring of the patient's health and correct any complications related to the procedure that may emerge. The objective of this article is to describe a case of penetrating trauma of the thoracic aorta that was treated endovascularly, since the literature predominantly covers blunt trauma injuries.
Assuntos
Humanos , Masculino , Adulto , Aorta Torácica/lesões , Procedimentos Endovasculares/métodos , Aorta Torácica/cirurgia , Ferimentos Perfurantes/cirurgia , Ferimentos Perfurantes/reabilitação , Procedimentos Endovasculares/reabilitaçãoRESUMO
Resumo Contexto As lesões de aorta nos traumatismos torácicos fechados possuem alta mortalidade pré-hospitalar e no serviço de emergência. O tratamento endovascular é um método de escolha para o tratamento dessas lesões; entretanto, muitos resultados em relação a essa abordagem permanecem desconhecidos. Objetivos O objetivo deste trabalho é descrever a experiência no tratamento endovascular de lesões traumáticas de aorta torácica em um centro de referência em trauma. Métodos Este trabalho trata-se de estudo descritivo realizado através da revisão de prontuários eletrônicos de pacientes vítimas de trauma contuso de aorta torácica, atendidos em um hospital de referência em trauma na cidade de Curitiba (Paraná, Brasil). Resultados Dezesseis pacientes foram incluídos no estudo. Todos os pacientes foram vítimas de acidente de trânsito, sendo que 75% dos acidentes ocorreram por colisão entre veículos. As lesões de aorta variaram de Grau I a IV, e a maioria dos pacientes apresentou lesão de grau II (50%). Todos os pacientes foram submetidos a terapia endovascular com implante de endoprótese sendo realizado em média 71 horas após o trauma. Dois pacientes evoluíram a óbito, porém de causas não relacionadas à lesão de aorta. Durante o seguimento, apenas dois pacientes apresentaram complicações (endoleak e progressão da dissecção). Conclusões O método endovascular é uma alternativa viável no tratamento de lesões de aorta torácica por trauma contuso. São necessários estudos randomizados e controlados a fim de reforçar a indicação desse método como terapia para esse tipo de lesão.
Abstract Background Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown. Objectives The aim of this study is to describe a specialist trauma center's experience with endovascular treatment of cases like these. Methods This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil). Results Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection). Conclusions The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.
Assuntos
Humanos , Masculino , Feminino , Adulto , Aorta Torácica/lesões , Acidentes de Trânsito , Procedimentos Endovasculares/métodos , Aorta Torácica/cirurgia , Motocicletas , Epidemiologia Descritiva , Estudos Retrospectivos , Emergências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentaçãoRESUMO
Bullet embolization of the arterial or venous systems is a rare complication of penetrating gunshot injuries. A 29-yearold man presented at the emergency department with a gunshot wound to the left arm, which had transfixed the arm and entered the thorax, with no exit wound. Initial radiographies showed a projectile in the upper left thigh. Contrastenhanced tomography showed a pseudo-aneurysm of the descending thoracic aorta and the bullet inside the proximal left superficial femoral artery. Physical examination found diminished left pedal pulses, and the patient complained of left toe numbness. Endovascular thoracic aortic pseudoaneurysm repair was performed, sealing the descending aortic orifice with an endograft, and thromboembolectomy/bullet retrieval was carried out via a left femoral incision, both successfully. Considering that diagnosis of missile emboli depends on a high degree of suspicion, physicians who manage gunshot wound patients must be acutely aware of the possibility of intravascular bullet embolism
A embolia balística pelo sistema arterial ou venoso é uma complicação rara de ferimentos penetrantes por arma de fogo. Um homem de 29 anos se apresentou na emergência com um ferimento por arma de fogo no braço esquerdo, que transfixou o braço e atingiu o tórax, sem ferimento de saída. Radiografias iniciais mostraram o projétil na coxa superior esquerda. A tomografia contrastada mostrou um pseudoaneurisma da aorta torácica descendente e o projétil no interior da artéria femoral superficial proximal esquerda. Ao exame físico, o pulso pedioso esquerdo estava diminuído e o paciente referiu dormência no hálux esquerdo. Foi realizado o reparo endovascular da aorta torácica e a tromboembolectomia/retirada do projétil por incisão femoral esquerda, ambos bem-sucedidos. Considerando que o diagnóstico de embolia balística depende de um alto grau de suspeição, os médicos que manejam pacientes com ferimentos por arma de fogo devem estar atentos a essa possibilidade
Assuntos
Humanos , Masculino , Adulto , Embolia , Artéria Femoral , Ferimentos por Arma de Fogo , Falso Aneurisma/complicações , Falso Aneurisma/diagnóstico , Aorta Torácica/lesões , Procedimentos Endovasculares/métodos , Artéria Femoral/lesões , Extremidade Inferior , Radiografia/métodos , Tromboembolia/complicações , Tomografia/métodos , Extremidade SuperiorRESUMO
OBJECTIVE: The traditional approach to stable blunt thoracic aortic injury (BTAI) endorsed by the Society for Vascular Surgery is early (<24 hours) thoracic endovascular aortic repair (TEVAR). Recently, some studies have shown improved mortality in stable BTAI patients repaired in a delayed manner (≥24 hours). However, the indications for use of delayed TEVAR for BTAI are not well characterized, and its overall impact on the patient's survival remains poorly understood. We sought to determine whether delayed TEVAR is associated with a decrease in mortality compared with early TEVAR in this population. METHODS: We conducted a retrospective cohort study of adult patients with BTAI (International Classification of Diseases, Ninth Revision diagnosis code 901.0) who underwent TEVAR (International Classification of Diseases, Ninth Revision procedure code 39.73) from 2009 to 2013 using the National Sample Program data set. Missing physiologic data were imputed using chained multiple imputation. Patients were parsed into groups based on the timing of TEVAR (early, <24 hours, vs delayed, ≥24 hours). The χ2, Mann-Whitney, and Fisher exact tests were used to compare baseline characteristics and outcomes of interest between groups. Multivariable logistic regression for mortality was performed that included all variables significant at P ≤ .2 in univariate analyses. RESULTS: A total of 2045 adult patients with BTAI were identified, of whom 534 (26%) underwent TEVAR. Patients with missing data on TEVAR timing were excluded (n = 27), leaving a total of 507 patients for analysis (75% male; 69% white; median age, 40 years [interquartile range, 27-56 years]; median Injury Severity Score [ISS], 34 [interquartile range, 26-41]). Of these, 378 patients underwent early TEVAR and 129 underwent delayed TEVAR. The two groups were similar with regard to age, sex, race, ISS, and presenting physiology. Mortality was 11.9% in the early TEVAR group vs 5.4% in the delayed group, with the early group displaying a higher odds of death (odds ratio, 2.36; 95% confidence interval, 1.03-5.36; P = .042). After adjustment for age, ISS, and admission physiology, the association between early TEVAR and mortality was preserved (adjusted odds ratio, 2.39; 95% confidence interval, 1.01-5.67; P = .047). CONCLUSIONS: Consistent with current Society for Vascular Surgery recommendations, more BTAI patients underwent early TEVAR than delayed TEVAR during the study period. However, delayed TEVAR was associated with significantly reduced mortality in this population. Together, these findings support a need for critical appraisal and clarification of existing practice guidelines in management of BTAI. Future studies should seek to understand this survival disparity and to determine optimal selection of patients for early vs delayed TEVAR.
Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar , Traumatismos Torácicos/cirurgia , Tempo para o Tratamento , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Implante de Prótese Vascular/efeitos adversos , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidadeRESUMO
We examined the contractile responsiveness of rat thoracic aortas under pressure overload after long-term suprarenal abdominal aortic coarctation (lt-Srac). Endothelium-dependent angiotensin II (ANG II) type 2 receptor (AT2R)-mediated depression of contractions to ANG II has been reported in short-term (1 week) pressure-overloaded rat aortas. Contractility was evaluated in the aortic rings of rats subjected to lt-Srac or sham surgery (Sham) for 8 weeks. ANG I and II levels and AT2R protein expression in the aortas of lt-Srac and Sham rats were also evaluated. lt-Srac attenuated the contractions of ANG II and phenylephrine in the aortas in an endothelium-independent manner. However, lt-Srac did not influence the transient contractions induced in endothelium-denuded aortic rings by ANG II, phenylephrine, or caffeine in Ca2+-free medium or the subsequent tonic constrictions induced by the addition of Ca2+ in the absence of agonists. Thus, the contractions induced by Ca2+ release from intracellular stores and Ca2+ influx through stored-operated channels were not inhibited in the aortas of lt-Srac rats. Potassium-elicited contractions in endothelium-denuded aortic rings of lt-Srac rats remained unaltered compared with control tissues. Consequently, the contractile depression observed in aortic tissues of lt-Srac rats cannot be explained by direct inhibition of voltage-operated Ca2+ channels. Interestingly, 12-O-tetradecanoylphorbol-13-acetate-induced contractions in endothelium-denuded aortic rings of lt-Srac rats were depressed in the presence but not in the absence of extracellular Ca2+. Neither levels of angiotensins nor of AT2R were modified in the aortas after lt-Srac. The results suggest that, in rat thoracic aortas, lt-Srac selectively inhibited protein kinase C-mediated activation of contraction that is dependent on extracellular Ca2+ entry.
Assuntos
Animais , Masculino , Aorta Torácica/fisiopatologia , Coartação Aórtica/fisiopatologia , Cálcio/metabolismo , Endotélio Vascular/fisiologia , Músculo Liso Vascular/fisiopatologia , Proteína Quinase C/antagonistas & inibidores , Vasoconstrição/fisiologia , Angiotensina I/análise , Angiotensina II/análise , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Western Blotting , Pressão Sanguínea/fisiologia , Cromatografia Líquida de Alta Pressão , Endotélio Vascular/lesões , Músculo Liso Vascular/metabolismo , Fármacos Neuromusculares Despolarizantes/farmacologia , Fenilefrina/farmacologia , Potássio/farmacologia , Proteína Quinase C/metabolismo , Radioimunoensaio , Ratos Wistar , /metabolismo , Vasoconstrição/efeitos dos fármacosRESUMO
We examined the contractile responsiveness of rat thoracic aortas under pressure overload after long-term suprarenal abdominal aortic coarctation (lt-Srac). Endothelium-dependent angiotensin II (ANG II) type 2 receptor (AT2R)-mediated depression of contractions to ANG II has been reported in short-term (1 week) pressure-overloaded rat aortas. Contractility was evaluated in the aortic rings of rats subjected to lt-Srac or sham surgery (Sham) for 8 weeks. ANG I and II levels and AT2R protein expression in the aortas of lt-Srac and Sham rats were also evaluated. lt-Srac attenuated the contractions of ANG II and phenylephrine in the aortas in an endothelium-independent manner. However, lt-Srac did not influence the transient contractions induced in endothelium-denuded aortic rings by ANG II, phenylephrine, or caffeine in Ca2+-free medium or the subsequent tonic constrictions induced by the addition of Ca2+ in the absence of agonists. Thus, the contractions induced by Ca2+ release from intracellular stores and Ca2+ influx through stored-operated channels were not inhibited in the aortas of lt-Srac rats. Potassium-elicited contractions in endothelium-denuded aortic rings of lt-Srac rats remained unaltered compared with control tissues. Consequently, the contractile depression observed in aortic tissues of lt-Srac rats cannot be explained by direct inhibition of voltage-operated Ca2+ channels. Interestingly, 12-O-tetradecanoylphorbol-13-acetate-induced contractions in endothelium-denuded aortic rings of lt-Srac rats were depressed in the presence but not in the absence of extracellular Ca2+. Neither levels of angiotensins nor of AT2R were modified in the aortas after lt-Srac. The results suggest that, in rat thoracic aortas, lt-Srac selectively inhibited protein kinase C-mediated activation of contraction that is dependent on extracellular Ca2+ entry.
Assuntos
Aorta Torácica/fisiopatologia , Coartação Aórtica/fisiopatologia , Cálcio/metabolismo , Endotélio Vascular/fisiologia , Músculo Liso Vascular/fisiopatologia , Proteína Quinase C/antagonistas & inibidores , Vasoconstrição/fisiologia , Angiotensina I/análise , Angiotensina II/análise , Animais , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Pressão Sanguínea/fisiologia , Western Blotting , Cromatografia Líquida de Alta Pressão , Endotélio Vascular/lesões , Masculino , Músculo Liso Vascular/metabolismo , Fármacos Neuromusculares Despolarizantes/farmacologia , Fenilefrina/farmacologia , Potássio/farmacologia , Proteína Quinase C/metabolismo , Radioimunoensaio , Ratos Wistar , Receptor Tipo 2 de Angiotensina/metabolismo , Vasoconstrição/efeitos dos fármacosRESUMO
Previous work from our laboratory and others has shown that, in some epithelia, the epithelial sodium channel (ENaC) increases its expression during wound healing. In these cases, inhibition of the channel determines a decrease in the healing rate, a result suggesting a role for ENaC in the overall healing process. To understand further this role of ENaC in epithelia, we explored the participation of ENaC in wound healing in four cultured epithelial cell lines selected on the basis of their different embryonic origins, function and modality of healing, i.e., by lamellipodial cell crawling or by actin cable formation. Three of the cell lines (bovine corneal endothelial cells, rabbit corneal epithelial cells and Madin-Darby canine kidney cells) exhibited an increase in ENaC expression and consequent membrane potential depolarization and an increase in cytosolic sodium and calcium, whereas one line (bovine aortal endothelial cells, BAEC) did not exhibit any of these changes. In all of the cell lines, however, ENaC inhibition determined a similar decrease in the rate of wound healing. In BAEC monolayers, the increase in ENaC activity produced plasma membrane depolarization, increased cytosolic sodium and calcium, and augmented the velocity of healing. These novel findings contribute to the idea that ENaC plays a critical role in wound healing in various epithelia, independently of the modality of healing and of any increase in the expression of the channel.
Assuntos
Aorta Torácica/metabolismo , Córnea/metabolismo , Canais Epiteliais de Sódio/metabolismo , Cicatrização/fisiologia , Animais , Antibacterianos/farmacologia , Aorta Torácica/citologia , Aorta Torácica/lesões , Bovinos , Linhagem Celular , Colforsina/farmacologia , Córnea/citologia , Lesões da Córnea , Cães , Células Epiteliais/metabolismo , Bloqueadores do Canal de Sódio Epitelial/farmacologia , Canais Epiteliais de Sódio/biossíntese , Epitélio/imunologia , Epitélio/metabolismo , Gramicidina/farmacologia , Células Madin Darby de Rim Canino , Potenciais da Membrana/fisiologia , Coelhos , Vasodilatadores/farmacologiaRESUMO
A 59-year-old female presented to our institution with paraparesis caused by medullar compression secondary to multiple myeloma. Spinal cord decompression and transpedicular spine fixation were performed. A month later, the patient complained of sudden pain in her middle back. A CT scan revealed screw impingement on the aortic wall at T8 level. A thoracic stent-graft was deployed before removing the fixation. The patient had an uneventful postoperative course, without complications during the four-year follow-up. In this case report, stent-graft placement proved to be safe and effective in avoiding bleeding during screw removal.