Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma.

BACKGROUND: Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C. METHODS: The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization. RESULTS: Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001). CONCLUSION: While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury.

BACKGROUND: Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility. METHODS: Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. RESULTS: Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. CONCLUSION: Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury. LEVEL OF EVIDENCE: Diagnostic, level III.

No wire? No problem: Resuscitative endovascular balloon occlusion of the aorta can be performed effectively and more rapidly with a wire-free device.

BACKGROUND: A wire-free device is available for resuscitative endovascular balloon occlusion of the aorta (REBOA) providing aortic occlusion (AO) without lengthy platform guide-wires and large sheaths. METHODS: This was a retrospective, single-institution review of patients who received REBOA from May 2014 to September 2017. Timing of procedural steps was measured in seconds using time-stamped videography. RESULTS: Seventy-four patients received REBOA: 29 with a platform guidewire, 12-Fr sheath, and balloon catheter (W group), and 45 with a 7-Fr sheath and wire-free device (WF group). Mean age (p = 0.22) and ISS (p = 0.80) were similar between groups. Fifty-nine patients received REBOA at Zone 1, 15 patients at Zone 3. There was no difference in median [interquartile range] time to common femoral artery (CFA) access between the WF (194 [98-313] seconds) and W (193 [126-280] seconds) groups (p = 0.96). Both median time to AO after CFA access (WF, 158 [109-264] seconds vs. W, 307 [222-390] seconds, p < 0.001) and median total procedural time (WF, 366 [263-596] seconds vs. W, 511 [441-597] seconds; p = 0.012) were significantly shorter with the wire-free system. The rates of percutaneous versus open CFA access was not different between groups (p = 0.48). Both groups had a similar physiologic response to AO as measured by pre- and post-AO SBP (p = 0.86). Overall mortality rate was 74%, 90% in the W group, and 64% in the WF group (p = 0.027). The procedure-related complication rate was not significantly different between groups with regard to compartment syndrome (W, 3% vs. WF, 4%, p = 1.0), access-related complications (W, 0 vs. WF, 6%, p = 0.28), or systemic complication (W, 0 vs. WF, 9%, p = 0.15). CONCLUSION: Once CFA access is obtained, AO with a smaller wire-free device reduces procedural time by approximately 50%. When perfusion to proximal organs is essential, the seconds saved to achieve AO may contribute to improved mortality. Time to obtain CFA access is not dependent on introducer sheath size. LEVEL OF EVIDENCE: Therapeutic, level V.