Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows

Evolution of conservative treatment of acute traumatic aortic injuries: lights and shadows Abstract OBJECTIVES The objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy. METHODS From January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores. RESULTS All but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, P = 0.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1 year, 68.2%, 80.8% and 79.4% at 5 years and 63.9%, 72.7% and 79.4% at 10 years, respectively (log-rank = 0.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; P = 0.021], Trauma Injury Severity Score >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011). CONCLUSIONS Minimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage. Medical management , Thoracic endovascular aortic repair , Aorta , Trauma , Surgery INTRODUCTION Presently, there is conflicting evidence regarding the indication for conservative treatment in patients with acute traumatic aortic injuries (ATAIs). Most publications agree that low-grade aortic injuries are amenable for a non-operative management strategy [1–3]. Additionally, there have been recent publications suggesting that medical management may be a suitable option for patients with more severe ATAIs [4, 5]. However, apart from our experience reported in 2011 [6], the long-term safety of conservative management and its effect on outcomes are poorly documented. Most contemporary studies [3–5, 7] focus only on in-hospital mortality and morbidity, and lack information about the long-term outcomes of medically-managed patients. In the technological era in which we practise, where advances in diagnostic and endovascular techniques demand improved results, it is important to consider long-term outcomes when selecting the most appropriate therapeutic strategy. The objective of this study is to compare, based on 37 years of experience, the early and long-term results in terms of survival and cardiovascular complications of multisystem trauma patients with ATAIs, who were conservatively managed with those who underwent either open surgical or endovascular repair. To the best of our knowledge, this is the largest single-centre series reported in the literature with the longest follow-up of patients with non-operatively managed ATAIs. PATIENTS AND METHODS From January 1980 to January 2017, 101 patients were admitted to our institution with ATAIs. Six patients were excluded from the analysis because of missing documentation of the time from injury to procedure and/or in extremis status on arrival [6]. As we have previously reported [6], data collected included age, gender, mechanism of injury, initial clinical presentation, Injury Severity Score (ISS), Abbreviated Injury Score (AIS) for each body area, Revised Trauma Score (RTS), Trauma Injury Severity Score (TRISS), Traumatic Aortic Injury Score (TRAINS) [8], method of diagnosis, type of aortic injury (Grades I–IV) [9], site of ATAI and type of definitive management (conservative, open repair or endovascular repair). An ISS of more than 50 points predicts a mortality rate of over 50%, while a score of more than 70 points predicts a mortality rate of nearly 100% [10]. The TRISS directly predicts the expected death rate for blunt trauma [11]. Patients were stratified according to ISS (ISS >50 points and ISS <50 points) and TRISS (TRISS >50% and TRISS <50%) to determine whether high scores might predict an unfavourable course in non-operated traumatic aortic injuries [6]. Patients were assigned to the conservative group when the initially intended management was highly delayed surgical repair (>15 days) or indefinite non-operative therapy [6]. The criteria for primary intended treatment were meticulously recorded and justified in every patient history chart by the multidisciplinary team which examined each patient on admission [6]. These criteria did not remain consistent over the observation period of 37 years and were modified with the incorporation of thoracic endovascular aortic repair (TEVAR) based on a modern risk-benefit evaluation and critical assessment of comorbidity status. Emergency (<24 h) endovascular aortic repair has been available at our institution only since January 2003 due to the need of an in-hospital stock of thoracic aortic endografts. Only 6 patients have required open surgical repair since 2003 and these patients were not suitable candidates for an endovascular repair due to anatomic considerations, mainly involving the ascending aorta or the aortic arch. The non-operative group included not only all patients with minimal aortic injuries, which have been previously defined as intimal tears <10 mm with minimal to no periaortic haematoma [12, 13], but also more severe aortic injuries in patients assessed as non-surgical candidates. Several patients from the conservative group required emergency surgical or endovascular treatment because of in-hospital, aortic-related complications during the first 15 days of hospitalization [6]. None of these cross-over patients were assigned to the surgical or endovascular group as their initial intended treatment was conservative. Between the years 1980 and 1999, the diagnosis relied primarily on aortography and transoesophageal echocardiography, as the use of computed tomography was not usual in an emergency setting. From 2000, the initial diagnosis of ATAI was established in all patients mainly using multidetector computed tomography (MDCT), whereas transoesophageal echocardiography was used as an auxiliary diagnostic test, when required. Aortography was performed in some patients at the discretion of the attending trauma team to further delineate the injury pattern. This imaging protocol has been described elsewhere [13]. The primary outcomes measured were in-hospital mortality, late mortality and long-term survival free from aortic-related complications. Conservative treatment This series enrolled 60 patients who were conservatively managed for their ATAIs. The non-operative group comprised patients deemed unsuitable for surgery (open or endovascular): 8 patients who refused surgery for religious reasons, 18 low-risk patients with minimal aortic injuries; and 34 high-risk patients, including those with severe concomitant injuries, advanced age, or other severe premorbid conditions. Our protocol for the medical management of ATAIs has already been reported on in previous publications [6, 13]. Regular radiological follow-up was indicated after discharge with a control thoracic MDCT at 3 and 6 months and annual magnetic resonance imaging (MRI) [6]. Open surgical repair Twenty-six patients underwent open surgery in this series, including 15 Dacron graft interpositions, 8 direct sutures and 3 patch repairs. Based on the time from injury to definitive aortic repair, 20 patients underwent emergency (<24 h) and 6 patients delayed (>24 h) open repair. A left heart bypass was established in 14 patients, and cardiopulmonary bypass in 4. In the remaining 8 patients, surgery was performed using a simple clamping technique (clamp and sew). Thoracic endovascular aortic repair treatment Fifteen patients underwent a TEVAR for their ATAIs. Thirteen patients underwent emergency (<24 h) and 4 delayed endovascular repair. Endovascular procedures were performed in an operating room with patients receiving general anaesthesia, as we have previously reported [6, 14] (Video 1). A Talent® thoracic stent graft was selected in the first 2 patients; a Valiant® thoracic stent graft, in 5 patients and, a Valiant Captivia® (Medtronic, World Medical Manufacturing Corp, Sunrise, FL, USA) thoracic stent graft in 8 subsequent patients. All patients required a single stent graft to cover the lesion. Video 1 Thoracic endovascular repair of a traumatic aortic transection at the level of the isthmus. Video 1 Thoracic endovascular repair of a traumatic aortic transection at the level of the isthmus. Close Statistical analysis The SPSS statistical program for Windows version 17.0 (SPSS, Chicago, IL, USA) was used to perform data analysis. Data are expressed as mean and standard deviation or median and range, when appropriate. The 37-year study period was divided into 3 decades (1980–1989; 1990–1999 and 2000–2009 years) and a 7-year period in order to identify possible changes in management with time. When needed, for bivariate analysis, proportions were compared with contingency tables by means of χ2 or Fisher’s exact tests and the Student’s t-test or Wilcoxon signed-rank test were used to compare means. A P-value of <0.05 was considered significant. Outcomes were compared among groups for the total study population, using one-way analysis of variance with Bonferroni adjustment. Actuarial estimates of survival were accomplished with Kaplan–Meier methods. Differences in probability of survival among groups were analysed with the log-rank (Mantel–Cox) test. Bivariate analysis was used to identify variables of potential influence in the probability of developing aortic-related complication during follow-up in the conservative group. Cox regression analysis was used to confirm or reject these variables. Adjusted odds ratio (OR), 95% confidence intervals and P-values were derived. RESULTS In-hospital results Epidemiological and clinical characteristics of the entire cohort and each treatment group are shown in Table 1. Most patients were males (82%) with a mean age of 43.44 ± 18.46 years. There were no significant differences between groups in terms of sex, but the mean patient age of conservative and TEVAR groups were significantly higher (P = 0.007). Table 1: Epidemiological and clinical characteristics in overall patients, conservative, TEVAR and surgical groups All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) ATAI: acute traumatic aortic injury; GCS: Glasgow coma scale; ISS: Injury Severity Score; RTS: Revised Trauma Score; SD: standard deviation; TEVAR: thoracic endovascular aortic repair; TRISS: Trauma Injury Severity Score; TRAINS: Traumatic Aortic Injury Score. Table 1: Epidemiological and clinical characteristics in overall patients, conservative, TEVAR and surgical groups All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) ATAI: acute traumatic aortic injury; GCS: Glasgow coma scale; ISS: Injury Severity Score; RTS: Revised Trauma Score; SD: standard deviation; TEVAR: thoracic endovascular aortic repair; TRISS: Trauma Injury Severity Score; TRAINS: Traumatic Aortic Injury Score. Most aortic injuries were located at the isthmus (60%), whereas the mid- and distal thoracic descending aorta (lower half from the 6th intercostal space down to T12) (16%) was the 2nd most common location (Table 1). There were differences regarding the location of the ATAI, but these differences did not reach statistical significance (P = 0.056). In fact, 93% of TEVAR patients presented with an aortic injury at the isthmus, as compared to 45% in the conservative group. There were statistically significant differences in terms of the severity of ATAIs (P < 0.001, Table 1). The conservative group enrolled mainly patients with Grades I and II injuries (73%), as compared to 93% of patients with Grade III or IV injuries in the TEVAR group. The most frequent cause of ATAI in our series was the frontal impact in a motor accident (49%), followed by a fall from a great height (16%) and motorcycle accident (15%) (Table 2). Table 2: Mechanisms of acute traumatic aortic injury Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Table 2: Mechanisms of acute traumatic aortic injury Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Expected mortality at admission was ≥50% according to an ISS >50 points in 29 (29%) patients, while overall mean expected death rate calculated by the TRISS was 36.28 ± 35.13%. Overall in-hospital mortality was 27%. In-hospital mortality reached 30% in the conservative group; 23% in the surgical group; 20% in the endovascular group. There was a clear trend towards a higher in-hospital mortality in the conservative group, but this was not statistically significant (P = 0.65). Causes of death are summarized in Table 1. Overall, the most common causes of death were directly related to the aortic injury (8 patients, 8%), namely, free aortic rupture in 5 cases, and mesenteric ischaemia due to distal organ malperfusion in the remaining 3 patients. In-hospital, aortic-related mortality occurred mainly in the conservative group with 7 (12%) deaths, as compared to only 1 such death in the operative group (2.4%) (P = 0.091). There were no retrograde aortic dissections. In the conservative group, 2 patients sustaining arch injuries involving the supra-aortic vessels presumably suffered an embolic focal ischaemic stroke, and another patient presented a non-fatal watershed cerebral infarction likely caused by severe hypotension during cardiac resuscitation. Another non-fatal watershed cerebral infarction occurred in an open surgical patient due to a hypotensive episode caused by massive haemorrhage. No patient in the surgical group experienced paraplegia after the aortic repair. However, postoperative left phrenic nerve palsy appeared in 5 patients and bilateral palsy in 1 patient after open surgical repair. One patient developed ischaemia as a result of femoral arterial occlusion and a 2nd patient developed femoral arterial thrombosis at the cannulation site. There were neither neurological nor device-related complications in patients treated by endografting. One endovascular patient underwent a left carotid to left subclavian artery by-pass at the time of the TEVAR because of the need to occlude the left subclavian artery to achieve a satisfactory proximal sealing. Long-term results Total follow-up was 1109.27 patient-years. Median follow-up was 9.5 years (range, 0–50 years). Overall survival estimated by the Kaplan–Meier method, including early mortality was 98.8% at 1 year, 88.1% at 5 years and 73% at 10 years. Cumulative survival in the conservative group was 71.7% at 1 year, 68.2% at 5 years and 63.9% at 10 years; in the surgical group, 80.8% at 1 and 5 years and 72.7% at 10 years, and in the endovascular group, 79.4% at 1, 5 and 10 years (log-rank= 0.206) (Fig. 1). Among patients who received conservative treatment, cumulative survival was significantly different depending on whether they had sustained a Grade I or a higher Grades (II–IV) aortic injury. Cumulative survival of Grade I ATAIs in this group was 100% at 1 and 5 years, and 86.7% at 10 years, as compared to 96.4% at 1 year, 92.9% at 5 years and 65.3% at 10 years (log-rank= 0.048) for higher grade ATAIs (Fig. 2). Figure 1: View largeDownload slide The Kaplan–Meier cumulative survival curves of the conservative, surgical and endovascular groups. TEVAR: thoracic endovascular aortic repair. Figure 1: View largeDownload slide The Kaplan–Meier cumulative survival curves of the conservative, surgical and endovascular groups. TEVAR: thoracic endovascular aortic repair. Figure 2: View largeDownload slide Kaplan–Meier survival curves of Grade I and higher Grades (II–IV) aortic injuries subgroups in the conservative cohort. Figure 2: View largeDownload slide Kaplan–Meier survival curves of Grade I and higher Grades (II–IV) aortic injuries subgroups in the conservative cohort. Total follow-up for aortic-related complications in the conservative group was 520.24 patient-years. In the conservative group, 58% (n = 35) patients suffered an aortic-related complication, accounting for a rate of incidence of aortic-related complications of 6.7% per patient-year. Cumulative survival free from aortic-related complications in the conservative group was 82.8% at 1 year, 80.6% at 5 years and 57.8% at 10 years (Fig. 3). Only 1 patient in the endovascular group suffered an aortic-related complication. This patient died of multisystem organ failure secondary to mesenteric ischaemia due to an acute aortic pseudocoarctation (Video 2), despite undergoing emergency TEVAR. There were no aortic-related complications in the surgical group. Video 2 Three-dimensional reconstruction of multidetector computed tomography demonstrating a severe traumatic aortic pseudocoarctation. Video 2 Three-dimensional reconstruction of multidetector computed tomography demonstrating a severe traumatic aortic pseudocoarctation. Close Figure 3: View largeDownload slide Cumulative survival free from aortic-related complications in the conservative group. Figure 3: View largeDownload slide Cumulative survival free from aortic-related complications in the conservative group. Bivariate analysis identified sex, age, ATAI grade >1, a TRISS >50%, an ISS >50 points, and the decade of treatment as variables of potential risk factors for developing aortic-related complications in the conservative group, of which only ATAI grade >I (OR 3.05; P = 0.021), TRISS >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011) were confirmed by Cox regression. Two different peaks in the complication rate of the conservative group could be identified namely, at 1st week in the early follow-up, and between the 1st and 3rd months after the blunt thoracic trauma. Figure 4 depicts the evolution in the management of ATAI in the last 37 years at our institution. The rate of conservative management (70% of patients) peaked in the 1st decade (1980–1989) with a significant drop (48% of patients) in the following decade, followed by a new rise after 2000 to 66%. On the contrary, the rate of open surgical repair was higher in the first 2 decades, representing the main treatment strategy in 52% of patients. However, the advent of TEVAR in 1999 reversed this trend and, in the last decade, TEVAR was applied to the 29.2% of patients with ATAIs, while open surgery to only 4.2% of patients during this time. Figure 4: View largeDownload slide This histogram depicts the evolution in the management of acute traumatic aortic injury in the last 37 years at our institution. Figure 4: View largeDownload slide This histogram depicts the evolution in the management of acute traumatic aortic injury in the last 37 years at our institution. DISCUSSION Despite the advent of TEVAR, the proportion of ATAI undergoing conservative management seems to remain stable over time. The rationale behind this is the increasing use of high-resolution diagnostic techniques, especially with the widespread use of MDCT in an emergency setting. In the early period of this study, most of ATAIs were conservatively managed because of technical difficulties and delayed diagnosis, as well as a significant surgical morbidity and mortality that limited the open repair to selected patients (30% of patients between 1980 and 1989). Subsequent advances in open repair tipped the equilibrium between conservative and open surgical management in favour of the latter, which became the first-choice treatment. This trend dramatically changed with the introduction of TEVAR that has been available on an emergency basis at our institution since 2003 [6]. Because of its minimal invasiveness and lower rate of complications, TEVAR has superseded open repair and is considered the first-line treatment for ATAIs [15, 16]. In fact, in our series, open surgery has been performed only in 4.2% of patients with ATAIs since 2000, who were mainly patients with traumatic injuries involving either the ascending aorta and the aortic arch [17] or in whom TEVAR was contraindicated for anatomical reasons. Despite advancements in endovascular techniques over the last decade, we have noticed a rise in the rate of patients selected for non-operative management mainly due to an increase in the diagnosis of minimal aortic injuries parallel to the widespread use of MDCT, which has been available at our institution for trauma emergencies since 2006 [8]. Emergency MDCT is the gold-standard technique for diagnosis of ATAIs [15, 16] and is a fast and accessible technique with a sensibility and specificity of nearly 100% [15, 18, 19], facilitating the multiplanar and tridimensional reconstruction of the aorta. In a previous publication [13], our group concluded that, with current diagnostic techniques, minimal aortic injuries may represent up to 20% of all ATAIs in patients sustaining blunt thoracic trauma. More recently, Gunn et al. [20] have estimated that minimal aortic injuries could be identified by MDCT in more than a quarter of cases of ATAIs and are associated with a low mortality. Our group has previously postulated that patients with blunt traumas presenting with minimal aortic injuries are, at least, are just as much as at risk for in-hospital mortality as those with high-grade aortic injuries, but, in contrast to the latter, in-hospital mortality in these patients is usually unrelated to the aortic injury [13]. The fate of the patients sustaining a Grade I ATAI who were non-operatively managed was significantly more favourable with a 100% survival at 5 years than those with a Grade II or greater ATAI. In a series of 97 patients with ATAI, among which 45 patients were conservatively managed, Rabin et al. [3] reported the importance of stratification by injury grade to identify potential candidates appropriate for medical management. The authors suggested that Grades I and II injuries are amenable to medical management [3]. More recently, Fortuna et al. [7] have also emphasized that injury grade is a predictor of aortic-related death among patients with ATAIs, reporting no mortality among patients with Grades I and II ATAIs. Beyond general agreement, in another recent publication, Gandhi et al. [5] surmised that even selected Grade III ATAIs may be an optimal target for medical management. The authors reported only 1 death among 18 patients with Grade III ATAIs who underwent a conservative approach. The current Society for Vascular Surgery Clinical Practice Guidelines suggest urgent TEVAR for Grade II to Grade IV ATAIs [21]. Another significant finding in our series was that the proportion of aortic-related complications among patients in the non-operative group was 58.3%. The rate of incidence of aortic-related complications was 6.7% per patient-year in the medically-managed group. Furthermore, Cox analysis revealed that a grade >I ATAI entailed a risk of long-term aortic-related complications 3 times higher than minimal aortic injuries. Conversely, the decade of treatment was associated with almost a 50% reduction of long-term aortic-related complications. All but 1 in-hospital aortic-related complications (free aortic rupture or progression of dissection) occurred in the conservative group and led to either a switch to an endovascular or surgical management or directly to patient death. Similarly, in-hospital mortality among patients conservatively managed reached 30% and tended to be higher than in the TEVAR (20%) and surgical (23.1%) groups. As we have previously reported [6], complication rates 1st peak during the 1st week, mainly as a result of patients with major or borderline aortic radiological injury. A 2nd peak occurs subsequently between the 1st and 3rd months after the thoracic trauma. This potential for the rapid development of aortic-related complications in major trauma patients, even those with minimal aortic injuries, mandates continuous radiological controls during the first 3 months after injury diagnosis and thereafter, at least, annually. Some authors have identified the potential adverse progression of minimal aortic injuries as the formation, enlargement and rupture of pseudoaneurysm; embolism of loose intima, or thrombus; and progressive dissection of the aortic wall [12, 23]. Conversely, we have previously found [13] a rate of spontaneous healing of up to 85.7% in surviving patients with these low-grade injuries. This study finally sheds light on an issue already highlighted by our group in 2011 [6]. Non-operative management may be a viable therapeutic option with acceptable survival in carefully selected patients, particularly in those with low-grade aortic injuries, as well as in patients with multiple severe associated injuries or high-risk comorbidities. However, due to the nature of these injuries, the initial benefit of conservative management is eventually eroded by progressive development of late aortic-related complications. This may justify the choice of an endovascular repair even in some low-risk patients. Because of these findings, we currently advocate the use of a combination of MDCT and echocardiography to monitor of low-grade aortic injuries amenable to medical management during the in-hospital stay. Subsequently, we recommend MRI for the yearly imaging surveillance after the 1st year of hospital discharge and not to perform MDCT surveillance, unless a new aortic anomaly is detected on the MRI. Limitations This study possesses the limitations inherent to any retrospective series. The conservative group was more heterogeneous and included both low-risk patients, of whom the majority could be managed safely with serial imaging (e.g. <10 mm intimal flaps) and in whom one would expect a low mortality, and the highest risk patients (e.g. elderly patients, severe comorbidities), in whom we would expect a higher mortality and an increased complication rate. Nevertheless, the 3 groups were similar regarding gender, age, presence of severe extrathoracic injuries and expected mortality, as calculated by current trauma scores. The criteria of primary intended treatment, as well as the diagnostic protocols, were obviously not consistent over the observation period of 37 years and was modified with the inclusion of technological advances in both diagnostic and therapeutic fields, especially with the spread of thoracic aorta endografting as we have previously published [6]. CONCLUSIONS In spite of advancements in endovascular techniques, the proportion of patients ATAI undergoing conservative management in the last decade appears to remain stable over time, mainly due to an increase in the number of diagnoses of minimal aortic injuries as a result of the widespread use of MDCT. Minimal or Grade I aortic injuries seem to be an amenable target for safe medical management, but patients remain at risk of developing aortic-related complications. A close long-term imaging surveillance is mandatory to detect such complications at an early stage, and even a preventive endovascular repair may be reasonable in some patients with low-grade injuries when a suboptimal evolution is anticipated. Physicians must be mindful of the inevitable trade-off between the consequences of long-term imaging surveillance and the risk of a preventive endovascular repair. Finally, non-operative management in high-grade aortic injuries is associated with an unacceptable rate of aortic-related complications in the long term. Therefore, should patients with a high-grade ATAI and severe extra-thoracic injuries recover from the associated non-aortic lesions, they must be considered for endovascular repair when feasible, given the ominous prognosis of conservative management in this critical subset of patients. Conflict of interest: none declared. REFERENCES 1 Fabian TC , Davis KA , Gavant ML , Croce MA , Melton SM , Patton JH. Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture . Ann Surg 1998 ; 227 : 666 – 76 . Google Scholar CrossRef Search ADS PubMed 2 Pate JW , Gavant ML , Weiman DS , Fabian TC. Traumatic rupture of the aortic isthmus: program of selective management . World J Surg 1999 ; 23 : 59 – 63 . Google Scholar CrossRef Search ADS PubMed 3 Rabin J , DuBose J , Sliker CW , O’Connor JV , Scalea TM , Griffith BP. Parameters for successful nonoperative management of traumatic aortic injury . J Thorac Cardiovasc Surg 2014 ; 147 : 143 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Harris DG , Rabin J , Bhardwaj A , June AS , Oates CP , Garrido D et al. Nonoperative management of traumatic aortic pseudoaneurysms . Ann Vasc Surg 2016 ; 35 : 75 – 81 . Google Scholar CrossRef Search ADS PubMed 5 Gandhi SS , Blas JV , Lee S , Eidt JF , Carsten CG 3rd . Nonoperative management of grade III blunt thoracic aortic injuries . 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Minimal traumatic aortic injuries: meaning and natural history . Interact CardioVasc Thorac Surg 2012 ; 14 : 773 – 8 . Google Scholar CrossRef Search ADS PubMed 14 Mosquera VX , Herrera JM , Marini M , Estevez F , Cao I , Gulias DV et al. Mid-term results of thoracic endovascular aortic repair in surgical high-risk patients . Interact CardioVasc Thorac Surg 2009 ; 9 : 61 – 5 . Google Scholar CrossRef Search ADS PubMed 15 Erbel R , Aboyans V , Boileau C , Bossone E , Bartolomeo RD , Eggebrecht H et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) . Eur Heart J 2014 ; 35 : 2873 – 926 . Google Scholar CrossRef Search ADS PubMed 16 Riambau V , Bockler D , Brunkwall J , Cao P , Chiesa R , Coppi G et al. Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS) . Eur J Vasc Endovasc Surg 2017 ; 53 : 4 – 52 . Google Scholar CrossRef Search ADS PubMed 17 Mosquera VX , Marini M , Muniz J , Gulias D , Asorey-Veiga V , Adrio-Nazar B et al. Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study . Injury 2013 ; 44 : 1191 – 7 . Google Scholar CrossRef Search ADS PubMed 18 Steenburg SD , Ravenel JG. Acute traumatic thoracic aortic injuries: experience with 64-MDCT . AJR Am J Roentgenol 2008 ; 191 : 1564 – 9 . Google Scholar CrossRef Search ADS PubMed 19 Nagpal P , Mullan BF , Sen I , Saboo SS , Khandelwal A. Advances in imaging and management trends of traumatic aortic injuries . Cardiovasc Intervent Radiol 2017 ; 40 : 643 – 54 . Google Scholar CrossRef Search ADS PubMed 20 Gunn ML , Lehnert BE , Lungren RS , Narparla CB , Mitsumori L , Gross JA et al. Minimal aortic injury of the thoracic aorta: imaging appearances and outcome . Emerg Radiol 2014 ; 21 : 227 – 33 . Google Scholar CrossRef Search ADS PubMed 21 Lee WA , Matsumura JS , Mitchell RS , Farber MA , Greenberg RK , Azizzadeh A et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery . J Vasc Surg 2011 ; 53 : 187 – 92 . Google Scholar CrossRef Search ADS PubMed 22 Holmes JH , Bloch RD , Hall RA , Carter YM , Karmy-Jones RC. Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis . Ann Thorac Surg 2002 ; 73 : 1149 – 54 . Google Scholar CrossRef Search ADS PubMed 23 Kepros J , Angood P , Jaffe CC , Rabinovici R. Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management . J Trauma 2002 ; 52 : 475 – 8 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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Abstract

Abstract OBJECTIVES The objective of this study is to compare early and long-term results in terms of survival and aortic complications for traumatic aortic injuries depending on the initial management strategy. METHODS From January 1980 to January 2017, 101 patients with aortic injuries were divided into 3 groups according to management strategy at admission: 60 patients, conservative management; 26 patients, open surgery and 15 patients, endovascular repair. The groups were similar in terms of gender and trauma severity scores. RESULTS All but 1 aortic-related complications and aortic-related mortality occurred in the conservative group (11.6% conservative vs 2.4% in both surgical and endovascular groups, P = 0.091). Total follow-up was 1109.27 patient-years. Survival in the conservative, surgical and endovascular group was 71.7%, 80.8% and 79.4% at 1 year, 68.2%, 80.8% and 79.4% at 5 years and 63.9%, 72.7% and 79.4% at 10 years, respectively (log-rank = 0.218). The rate of aortic-related complications was 58.3% in the conservative cohort. Cox regression identified the following risk factors for aortic-related complications: aortic injuries grade >I [odds ratio (OR), 3.05; P = 0.021], Trauma Injury Severity Score >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011). CONCLUSIONS Minimal aortic injuries seem to be an amenable target for medical management, but patients remain at risk of developing aortic-related complications. Close, long-term imaging surveillance is mandatory to detect such complications at an early stage. Medical management , Thoracic endovascular aortic repair , Aorta , Trauma , Surgery INTRODUCTION Presently, there is conflicting evidence regarding the indication for conservative treatment in patients with acute traumatic aortic injuries (ATAIs). Most publications agree that low-grade aortic injuries are amenable for a non-operative management strategy [1–3]. Additionally, there have been recent publications suggesting that medical management may be a suitable option for patients with more severe ATAIs [4, 5]. However, apart from our experience reported in 2011 [6], the long-term safety of conservative management and its effect on outcomes are poorly documented. Most contemporary studies [3–5, 7] focus only on in-hospital mortality and morbidity, and lack information about the long-term outcomes of medically-managed patients. In the technological era in which we practise, where advances in diagnostic and endovascular techniques demand improved results, it is important to consider long-term outcomes when selecting the most appropriate therapeutic strategy. The objective of this study is to compare, based on 37 years of experience, the early and long-term results in terms of survival and cardiovascular complications of multisystem trauma patients with ATAIs, who were conservatively managed with those who underwent either open surgical or endovascular repair. To the best of our knowledge, this is the largest single-centre series reported in the literature with the longest follow-up of patients with non-operatively managed ATAIs. PATIENTS AND METHODS From January 1980 to January 2017, 101 patients were admitted to our institution with ATAIs. Six patients were excluded from the analysis because of missing documentation of the time from injury to procedure and/or in extremis status on arrival [6]. As we have previously reported [6], data collected included age, gender, mechanism of injury, initial clinical presentation, Injury Severity Score (ISS), Abbreviated Injury Score (AIS) for each body area, Revised Trauma Score (RTS), Trauma Injury Severity Score (TRISS), Traumatic Aortic Injury Score (TRAINS) [8], method of diagnosis, type of aortic injury (Grades I–IV) [9], site of ATAI and type of definitive management (conservative, open repair or endovascular repair). An ISS of more than 50 points predicts a mortality rate of over 50%, while a score of more than 70 points predicts a mortality rate of nearly 100% [10]. The TRISS directly predicts the expected death rate for blunt trauma [11]. Patients were stratified according to ISS (ISS >50 points and ISS <50 points) and TRISS (TRISS >50% and TRISS <50%) to determine whether high scores might predict an unfavourable course in non-operated traumatic aortic injuries [6]. Patients were assigned to the conservative group when the initially intended management was highly delayed surgical repair (>15 days) or indefinite non-operative therapy [6]. The criteria for primary intended treatment were meticulously recorded and justified in every patient history chart by the multidisciplinary team which examined each patient on admission [6]. These criteria did not remain consistent over the observation period of 37 years and were modified with the incorporation of thoracic endovascular aortic repair (TEVAR) based on a modern risk-benefit evaluation and critical assessment of comorbidity status. Emergency (<24 h) endovascular aortic repair has been available at our institution only since January 2003 due to the need of an in-hospital stock of thoracic aortic endografts. Only 6 patients have required open surgical repair since 2003 and these patients were not suitable candidates for an endovascular repair due to anatomic considerations, mainly involving the ascending aorta or the aortic arch. The non-operative group included not only all patients with minimal aortic injuries, which have been previously defined as intimal tears <10 mm with minimal to no periaortic haematoma [12, 13], but also more severe aortic injuries in patients assessed as non-surgical candidates. Several patients from the conservative group required emergency surgical or endovascular treatment because of in-hospital, aortic-related complications during the first 15 days of hospitalization [6]. None of these cross-over patients were assigned to the surgical or endovascular group as their initial intended treatment was conservative. Between the years 1980 and 1999, the diagnosis relied primarily on aortography and transoesophageal echocardiography, as the use of computed tomography was not usual in an emergency setting. From 2000, the initial diagnosis of ATAI was established in all patients mainly using multidetector computed tomography (MDCT), whereas transoesophageal echocardiography was used as an auxiliary diagnostic test, when required. Aortography was performed in some patients at the discretion of the attending trauma team to further delineate the injury pattern. This imaging protocol has been described elsewhere [13]. The primary outcomes measured were in-hospital mortality, late mortality and long-term survival free from aortic-related complications. Conservative treatment This series enrolled 60 patients who were conservatively managed for their ATAIs. The non-operative group comprised patients deemed unsuitable for surgery (open or endovascular): 8 patients who refused surgery for religious reasons, 18 low-risk patients with minimal aortic injuries; and 34 high-risk patients, including those with severe concomitant injuries, advanced age, or other severe premorbid conditions. Our protocol for the medical management of ATAIs has already been reported on in previous publications [6, 13]. Regular radiological follow-up was indicated after discharge with a control thoracic MDCT at 3 and 6 months and annual magnetic resonance imaging (MRI) [6]. Open surgical repair Twenty-six patients underwent open surgery in this series, including 15 Dacron graft interpositions, 8 direct sutures and 3 patch repairs. Based on the time from injury to definitive aortic repair, 20 patients underwent emergency (<24 h) and 6 patients delayed (>24 h) open repair. A left heart bypass was established in 14 patients, and cardiopulmonary bypass in 4. In the remaining 8 patients, surgery was performed using a simple clamping technique (clamp and sew). Thoracic endovascular aortic repair treatment Fifteen patients underwent a TEVAR for their ATAIs. Thirteen patients underwent emergency (<24 h) and 4 delayed endovascular repair. Endovascular procedures were performed in an operating room with patients receiving general anaesthesia, as we have previously reported [6, 14] (Video 1). A Talent® thoracic stent graft was selected in the first 2 patients; a Valiant® thoracic stent graft, in 5 patients and, a Valiant Captivia® (Medtronic, World Medical Manufacturing Corp, Sunrise, FL, USA) thoracic stent graft in 8 subsequent patients. All patients required a single stent graft to cover the lesion. Video 1 Thoracic endovascular repair of a traumatic aortic transection at the level of the isthmus. Video 1 Thoracic endovascular repair of a traumatic aortic transection at the level of the isthmus. Close Statistical analysis The SPSS statistical program for Windows version 17.0 (SPSS, Chicago, IL, USA) was used to perform data analysis. Data are expressed as mean and standard deviation or median and range, when appropriate. The 37-year study period was divided into 3 decades (1980–1989; 1990–1999 and 2000–2009 years) and a 7-year period in order to identify possible changes in management with time. When needed, for bivariate analysis, proportions were compared with contingency tables by means of χ2 or Fisher’s exact tests and the Student’s t-test or Wilcoxon signed-rank test were used to compare means. A P-value of <0.05 was considered significant. Outcomes were compared among groups for the total study population, using one-way analysis of variance with Bonferroni adjustment. Actuarial estimates of survival were accomplished with Kaplan–Meier methods. Differences in probability of survival among groups were analysed with the log-rank (Mantel–Cox) test. Bivariate analysis was used to identify variables of potential influence in the probability of developing aortic-related complication during follow-up in the conservative group. Cox regression analysis was used to confirm or reject these variables. Adjusted odds ratio (OR), 95% confidence intervals and P-values were derived. RESULTS In-hospital results Epidemiological and clinical characteristics of the entire cohort and each treatment group are shown in Table 1. Most patients were males (82%) with a mean age of 43.44 ± 18.46 years. There were no significant differences between groups in terms of sex, but the mean patient age of conservative and TEVAR groups were significantly higher (P = 0.007). Table 1: Epidemiological and clinical characteristics in overall patients, conservative, TEVAR and surgical groups All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) ATAI: acute traumatic aortic injury; GCS: Glasgow coma scale; ISS: Injury Severity Score; RTS: Revised Trauma Score; SD: standard deviation; TEVAR: thoracic endovascular aortic repair; TRISS: Trauma Injury Severity Score; TRAINS: Traumatic Aortic Injury Score. Table 1: Epidemiological and clinical characteristics in overall patients, conservative, TEVAR and surgical groups All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) All patients (n = 101) Conservative group (n = 60) Surgical group (n = 26) TEVAR group (n = 15) P-value Male, n (%) 83 (82) 49 (82) 20 (77) 14 (93) 0.41 Age (years), mean ± SD 43.44 ± 18.47 45.73 ± 19.59 34.23 ± 13.73 50.40 ± 15.89 0.007 Age >55 (years), n (%) 30 (30) 27 (45) 2 (7.7) 5 (33) 0.014 GCS, mean ± SD 11.68 ± 4.35 11.55 ± 4.45 11.50 ± 4.35 12.47 ± 4.19 0.75 ISS, mean ± SD 39.93 ± 16.15 39.93 ± 16.15 37.85 ± 8.97 46.43 ± 14.20 0.18 RTS, mean ± SD 6.22 ± 1.68 6.14 ± 1.67 6.18 ± 1.65 6.59 ± 1.81 0.66 TRISS, mean ± SD 36.28 ± 35.13 40.10 ± 37.57 29.00 ± 31.14 34.77 ± 32.00 0.41 TRAINS, mean ± SD 8.05 ± 2.57 7.75 ± 2.88 8.65 ± 1.85 8.14 ± 2.35 0.33 Localization of ATAI, n (%) 0.056  Ascending aorta 3 (3) 2 (3) 1 (4) 0  Aortic arch 12 (12) 10 (17) 2 (8) 0  Isthmus 61 (60) 27 (45) 20 (77) 14 (93)  Mid- and distal thoracic aorta 16 (16) 14 (23) 2 (8) 0  Abdominal aorta 9 (9) 7 (12) 1 (3.8) 1 (7) Severity of ATAI grade, n (%) <0.001  I 22 (22) 18 (30) 4 (15) 0  II 27 (27) 26 (44) 0 1 (7)  III 22 (22) 12 (20) 6 (23) 4 (27)  IV 30 (30) 4 (7) 16 (62) 10 (67) In-hospital mortality, n (%) 27 (27) 18 (30) 6 (23) 3 (20) 0.65 Cause of mortality, n (%) 0.69  Hypovolemic shock 4 (4) 3 (5) 1 (4) 0  Multisystem failure 5 (5) 3 (5) 1 (4) 1 (7)  Late non-cardiac complication 8 (8) 6 (10) 2 (8) 0  Acute respiratory distress syndrome 1 (1) 0 1 (4) 0  Aortic-related death 8 (8) 7 (12) 0 1 (1)  Neurological complication 4 (4) 3 (5) 1 (4) 0  Septic shock 4 (4) 2 (3) 1 (4) 1 (7) ATAI: acute traumatic aortic injury; GCS: Glasgow coma scale; ISS: Injury Severity Score; RTS: Revised Trauma Score; SD: standard deviation; TEVAR: thoracic endovascular aortic repair; TRISS: Trauma Injury Severity Score; TRAINS: Traumatic Aortic Injury Score. Most aortic injuries were located at the isthmus (60%), whereas the mid- and distal thoracic descending aorta (lower half from the 6th intercostal space down to T12) (16%) was the 2nd most common location (Table 1). There were differences regarding the location of the ATAI, but these differences did not reach statistical significance (P = 0.056). In fact, 93% of TEVAR patients presented with an aortic injury at the isthmus, as compared to 45% in the conservative group. There were statistically significant differences in terms of the severity of ATAIs (P < 0.001, Table 1). The conservative group enrolled mainly patients with Grades I and II injuries (73%), as compared to 93% of patients with Grade III or IV injuries in the TEVAR group. The most frequent cause of ATAI in our series was the frontal impact in a motor accident (49%), followed by a fall from a great height (16%) and motorcycle accident (15%) (Table 2). Table 2: Mechanisms of acute traumatic aortic injury Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Table 2: Mechanisms of acute traumatic aortic injury Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Mechanism No. of patients (%) Motor vehicle crash (frontal impact) 50 (49.5) Falls 16 (15.8) Motorcycle 15 (14.9) Motor vehicle crash (lateral impact) 8 (7.9) Vehicle–pedestrian 6 (5.9) Crushed under weight 6 (5.9) Expected mortality at admission was ≥50% according to an ISS >50 points in 29 (29%) patients, while overall mean expected death rate calculated by the TRISS was 36.28 ± 35.13%. Overall in-hospital mortality was 27%. In-hospital mortality reached 30% in the conservative group; 23% in the surgical group; 20% in the endovascular group. There was a clear trend towards a higher in-hospital mortality in the conservative group, but this was not statistically significant (P = 0.65). Causes of death are summarized in Table 1. Overall, the most common causes of death were directly related to the aortic injury (8 patients, 8%), namely, free aortic rupture in 5 cases, and mesenteric ischaemia due to distal organ malperfusion in the remaining 3 patients. In-hospital, aortic-related mortality occurred mainly in the conservative group with 7 (12%) deaths, as compared to only 1 such death in the operative group (2.4%) (P = 0.091). There were no retrograde aortic dissections. In the conservative group, 2 patients sustaining arch injuries involving the supra-aortic vessels presumably suffered an embolic focal ischaemic stroke, and another patient presented a non-fatal watershed cerebral infarction likely caused by severe hypotension during cardiac resuscitation. Another non-fatal watershed cerebral infarction occurred in an open surgical patient due to a hypotensive episode caused by massive haemorrhage. No patient in the surgical group experienced paraplegia after the aortic repair. However, postoperative left phrenic nerve palsy appeared in 5 patients and bilateral palsy in 1 patient after open surgical repair. One patient developed ischaemia as a result of femoral arterial occlusion and a 2nd patient developed femoral arterial thrombosis at the cannulation site. There were neither neurological nor device-related complications in patients treated by endografting. One endovascular patient underwent a left carotid to left subclavian artery by-pass at the time of the TEVAR because of the need to occlude the left subclavian artery to achieve a satisfactory proximal sealing. Long-term results Total follow-up was 1109.27 patient-years. Median follow-up was 9.5 years (range, 0–50 years). Overall survival estimated by the Kaplan–Meier method, including early mortality was 98.8% at 1 year, 88.1% at 5 years and 73% at 10 years. Cumulative survival in the conservative group was 71.7% at 1 year, 68.2% at 5 years and 63.9% at 10 years; in the surgical group, 80.8% at 1 and 5 years and 72.7% at 10 years, and in the endovascular group, 79.4% at 1, 5 and 10 years (log-rank= 0.206) (Fig. 1). Among patients who received conservative treatment, cumulative survival was significantly different depending on whether they had sustained a Grade I or a higher Grades (II–IV) aortic injury. Cumulative survival of Grade I ATAIs in this group was 100% at 1 and 5 years, and 86.7% at 10 years, as compared to 96.4% at 1 year, 92.9% at 5 years and 65.3% at 10 years (log-rank= 0.048) for higher grade ATAIs (Fig. 2). Figure 1: View largeDownload slide The Kaplan–Meier cumulative survival curves of the conservative, surgical and endovascular groups. TEVAR: thoracic endovascular aortic repair. Figure 1: View largeDownload slide The Kaplan–Meier cumulative survival curves of the conservative, surgical and endovascular groups. TEVAR: thoracic endovascular aortic repair. Figure 2: View largeDownload slide Kaplan–Meier survival curves of Grade I and higher Grades (II–IV) aortic injuries subgroups in the conservative cohort. Figure 2: View largeDownload slide Kaplan–Meier survival curves of Grade I and higher Grades (II–IV) aortic injuries subgroups in the conservative cohort. Total follow-up for aortic-related complications in the conservative group was 520.24 patient-years. In the conservative group, 58% (n = 35) patients suffered an aortic-related complication, accounting for a rate of incidence of aortic-related complications of 6.7% per patient-year. Cumulative survival free from aortic-related complications in the conservative group was 82.8% at 1 year, 80.6% at 5 years and 57.8% at 10 years (Fig. 3). Only 1 patient in the endovascular group suffered an aortic-related complication. This patient died of multisystem organ failure secondary to mesenteric ischaemia due to an acute aortic pseudocoarctation (Video 2), despite undergoing emergency TEVAR. There were no aortic-related complications in the surgical group. Video 2 Three-dimensional reconstruction of multidetector computed tomography demonstrating a severe traumatic aortic pseudocoarctation. Video 2 Three-dimensional reconstruction of multidetector computed tomography demonstrating a severe traumatic aortic pseudocoarctation. Close Figure 3: View largeDownload slide Cumulative survival free from aortic-related complications in the conservative group. Figure 3: View largeDownload slide Cumulative survival free from aortic-related complications in the conservative group. Bivariate analysis identified sex, age, ATAI grade >1, a TRISS >50%, an ISS >50 points, and the decade of treatment as variables of potential risk factors for developing aortic-related complications in the conservative group, of which only ATAI grade >I (OR 3.05; P = 0.021), TRISS >50% (OR 1.21; P = 0.042) and the decade of treatment (OR 0.49; P = 0.011) were confirmed by Cox regression. Two different peaks in the complication rate of the conservative group could be identified namely, at 1st week in the early follow-up, and between the 1st and 3rd months after the blunt thoracic trauma. Figure 4 depicts the evolution in the management of ATAI in the last 37 years at our institution. The rate of conservative management (70% of patients) peaked in the 1st decade (1980–1989) with a significant drop (48% of patients) in the following decade, followed by a new rise after 2000 to 66%. On the contrary, the rate of open surgical repair was higher in the first 2 decades, representing the main treatment strategy in 52% of patients. However, the advent of TEVAR in 1999 reversed this trend and, in the last decade, TEVAR was applied to the 29.2% of patients with ATAIs, while open surgery to only 4.2% of patients during this time. Figure 4: View largeDownload slide This histogram depicts the evolution in the management of acute traumatic aortic injury in the last 37 years at our institution. Figure 4: View largeDownload slide This histogram depicts the evolution in the management of acute traumatic aortic injury in the last 37 years at our institution. DISCUSSION Despite the advent of TEVAR, the proportion of ATAI undergoing conservative management seems to remain stable over time. The rationale behind this is the increasing use of high-resolution diagnostic techniques, especially with the widespread use of MDCT in an emergency setting. In the early period of this study, most of ATAIs were conservatively managed because of technical difficulties and delayed diagnosis, as well as a significant surgical morbidity and mortality that limited the open repair to selected patients (30% of patients between 1980 and 1989). Subsequent advances in open repair tipped the equilibrium between conservative and open surgical management in favour of the latter, which became the first-choice treatment. This trend dramatically changed with the introduction of TEVAR that has been available on an emergency basis at our institution since 2003 [6]. Because of its minimal invasiveness and lower rate of complications, TEVAR has superseded open repair and is considered the first-line treatment for ATAIs [15, 16]. In fact, in our series, open surgery has been performed only in 4.2% of patients with ATAIs since 2000, who were mainly patients with traumatic injuries involving either the ascending aorta and the aortic arch [17] or in whom TEVAR was contraindicated for anatomical reasons. Despite advancements in endovascular techniques over the last decade, we have noticed a rise in the rate of patients selected for non-operative management mainly due to an increase in the diagnosis of minimal aortic injuries parallel to the widespread use of MDCT, which has been available at our institution for trauma emergencies since 2006 [8]. Emergency MDCT is the gold-standard technique for diagnosis of ATAIs [15, 16] and is a fast and accessible technique with a sensibility and specificity of nearly 100% [15, 18, 19], facilitating the multiplanar and tridimensional reconstruction of the aorta. In a previous publication [13], our group concluded that, with current diagnostic techniques, minimal aortic injuries may represent up to 20% of all ATAIs in patients sustaining blunt thoracic trauma. More recently, Gunn et al. [20] have estimated that minimal aortic injuries could be identified by MDCT in more than a quarter of cases of ATAIs and are associated with a low mortality. Our group has previously postulated that patients with blunt traumas presenting with minimal aortic injuries are, at least, are just as much as at risk for in-hospital mortality as those with high-grade aortic injuries, but, in contrast to the latter, in-hospital mortality in these patients is usually unrelated to the aortic injury [13]. The fate of the patients sustaining a Grade I ATAI who were non-operatively managed was significantly more favourable with a 100% survival at 5 years than those with a Grade II or greater ATAI. In a series of 97 patients with ATAI, among which 45 patients were conservatively managed, Rabin et al. [3] reported the importance of stratification by injury grade to identify potential candidates appropriate for medical management. The authors suggested that Grades I and II injuries are amenable to medical management [3]. More recently, Fortuna et al. [7] have also emphasized that injury grade is a predictor of aortic-related death among patients with ATAIs, reporting no mortality among patients with Grades I and II ATAIs. Beyond general agreement, in another recent publication, Gandhi et al. [5] surmised that even selected Grade III ATAIs may be an optimal target for medical management. The authors reported only 1 death among 18 patients with Grade III ATAIs who underwent a conservative approach. The current Society for Vascular Surgery Clinical Practice Guidelines suggest urgent TEVAR for Grade II to Grade IV ATAIs [21]. Another significant finding in our series was that the proportion of aortic-related complications among patients in the non-operative group was 58.3%. The rate of incidence of aortic-related complications was 6.7% per patient-year in the medically-managed group. Furthermore, Cox analysis revealed that a grade >I ATAI entailed a risk of long-term aortic-related complications 3 times higher than minimal aortic injuries. Conversely, the decade of treatment was associated with almost a 50% reduction of long-term aortic-related complications. All but 1 in-hospital aortic-related complications (free aortic rupture or progression of dissection) occurred in the conservative group and led to either a switch to an endovascular or surgical management or directly to patient death. Similarly, in-hospital mortality among patients conservatively managed reached 30% and tended to be higher than in the TEVAR (20%) and surgical (23.1%) groups. As we have previously reported [6], complication rates 1st peak during the 1st week, mainly as a result of patients with major or borderline aortic radiological injury. A 2nd peak occurs subsequently between the 1st and 3rd months after the thoracic trauma. This potential for the rapid development of aortic-related complications in major trauma patients, even those with minimal aortic injuries, mandates continuous radiological controls during the first 3 months after injury diagnosis and thereafter, at least, annually. Some authors have identified the potential adverse progression of minimal aortic injuries as the formation, enlargement and rupture of pseudoaneurysm; embolism of loose intima, or thrombus; and progressive dissection of the aortic wall [12, 23]. Conversely, we have previously found [13] a rate of spontaneous healing of up to 85.7% in surviving patients with these low-grade injuries. This study finally sheds light on an issue already highlighted by our group in 2011 [6]. Non-operative management may be a viable therapeutic option with acceptable survival in carefully selected patients, particularly in those with low-grade aortic injuries, as well as in patients with multiple severe associated injuries or high-risk comorbidities. However, due to the nature of these injuries, the initial benefit of conservative management is eventually eroded by progressive development of late aortic-related complications. This may justify the choice of an endovascular repair even in some low-risk patients. Because of these findings, we currently advocate the use of a combination of MDCT and echocardiography to monitor of low-grade aortic injuries amenable to medical management during the in-hospital stay. Subsequently, we recommend MRI for the yearly imaging surveillance after the 1st year of hospital discharge and not to perform MDCT surveillance, unless a new aortic anomaly is detected on the MRI. Limitations This study possesses the limitations inherent to any retrospective series. The conservative group was more heterogeneous and included both low-risk patients, of whom the majority could be managed safely with serial imaging (e.g. <10 mm intimal flaps) and in whom one would expect a low mortality, and the highest risk patients (e.g. elderly patients, severe comorbidities), in whom we would expect a higher mortality and an increased complication rate. Nevertheless, the 3 groups were similar regarding gender, age, presence of severe extrathoracic injuries and expected mortality, as calculated by current trauma scores. The criteria of primary intended treatment, as well as the diagnostic protocols, were obviously not consistent over the observation period of 37 years and was modified with the inclusion of technological advances in both diagnostic and therapeutic fields, especially with the spread of thoracic aorta endografting as we have previously published [6]. CONCLUSIONS In spite of advancements in endovascular techniques, the proportion of patients ATAI undergoing conservative management in the last decade appears to remain stable over time, mainly due to an increase in the number of diagnoses of minimal aortic injuries as a result of the widespread use of MDCT. Minimal or Grade I aortic injuries seem to be an amenable target for safe medical management, but patients remain at risk of developing aortic-related complications. A close long-term imaging surveillance is mandatory to detect such complications at an early stage, and even a preventive endovascular repair may be reasonable in some patients with low-grade injuries when a suboptimal evolution is anticipated. Physicians must be mindful of the inevitable trade-off between the consequences of long-term imaging surveillance and the risk of a preventive endovascular repair. Finally, non-operative management in high-grade aortic injuries is associated with an unacceptable rate of aortic-related complications in the long term. Therefore, should patients with a high-grade ATAI and severe extra-thoracic injuries recover from the associated non-aortic lesions, they must be considered for endovascular repair when feasible, given the ominous prognosis of conservative management in this critical subset of patients. Conflict of interest: none declared. REFERENCES 1 Fabian TC , Davis KA , Gavant ML , Croce MA , Melton SM , Patton JH. 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Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 11, 2018

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