Endovascular repair for blunt thoracic aortic injury: 11-year outcomes and postoperative surveillance experience.

OBJECTIVE: Surveillance for patients undergoing thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) varies. Annual chest computed tomographic angiography (CTA) is often recommended but concerns about the risks and costs have emerged. The aim of this study was to examine the optimal follow-up frequency based on 11-year outcomes and surveillance experience. METHODS: Seventy-six patients with BTAI received TEVAR from May 2002 to July 2013. Demographics, cardiovascular risk factors, Injury Severity Score (ISS), types, sizes, timing, and outcomes of stent grafts were collected retrospectively. RESULTS: Mean age was 39.7 years (range, 17-85 years); 8 (11%) were women. Mean ISS was 46.2 ± 18.5 (deceased, 61.0 ± 19.2; surviving, 44.2 ± 17.6; P = .023). Technical success was achieved in 71 patients (93.4%). All-cause mortality was 7 (9.2%), 1 (1.3%) of which was related to the procedure. Six were lost to follow-up (8%). To examine the effect of surveillance frequency on outcomes, after excluding the 2 most recent (<1 year) surviving patients, we arbitrarily divided the remaining 61 with stable repairs based on the timing of their follow-up: 36 underwent timely follow-up (within ± 6 months of the scheduled annual visit; clinical examination, CTA, magnetic resonance angiography, and echocardiography); 25 had delayed follow-up (>6 months after scheduled annual visit). No significant differences were found for survival, graft-related complications, need for reintervention, except for postoperative hypertension, which was higher in the first group. All surviving patients had excellent outcomes, with no cerebrovascular accidents, paraplegia, or paraparesis; the median follow-up for both groups was 3 years (interquartile range 2.0-3.5, 1.5-5.4 years). CONCLUSIONS: Midterm outcomes of TEVAR for patients with stable repair after BTAI are excellent, both with timely (1.0-1.5 years) and delayed (>1.5 years) follow-up intervals after a median surveillance period of 3 years. A larger prospective randomized study could lead to a more relaxed, but equally safe surveillance schedule for these patients, lowering risks and costs.

Comparison of monopolar electrocoagulation, bipolar electrocoagulation, Ultracision, and Ligasure.

PURPOSE: Hemostasis is a fundamental principle of surgery. We compared the safety and efficacy of monopolar electrocoagulation (ME), bipolar electrocoagulation (BE), Ligasure (LS), a modern bipolar vessel sealing system, and Ultracision (UC), a system of ultrasound energy based shears. We also studied the healing process after their use. METHODS: We used each of the above methods to coagulate and divide the short gastric vessels of 16 white male New Zealand rabbits. The animals were killed after 3, 7, 14, or 21 days, and the coagulation sites and the adjacent gastric wall were examined histologically. RESULTS: LS and UC achieved complete hemostasis without any complications. Conversely, ME and BE often resulted in failed coagulation and perforation of the neighboring gastric wall from a side thermal injury. Histologically, LS demonstrated the mildest side thermal injury and the fastest healing process. We noted greater thermal injury and inflammatory response after UC than after LS on days 7 and 14; however, ME and BE caused the most severe lesions. CONCLUSIONS: LS and UC are clearly the safest and most efficient methods of coagulation, whereas ME and BE could cause serious clinical and histological complications. We found histological evidence that UC causes a slightly greater inflammatory response than LS, and the clinical implications of this warrant further investigation.