The pattern of acute injuries in patients from alpine skiing accidents has changed during 2000-2011: analysis of clinical and radiological data at a level I trauma center.

OBJECTIVES: During the last decade, many educational efforts and technological improvements have been made to protect skiing athletes from injuries. Whether these efforts have changed the pattern of acute injuries from skiing casualties has not yet been shown on a medical basis, which this longitudinal study examines. METHODS: All patients transferred to the Department of Radiology of our level I trauma center for acute emergency computed tomography (CT) after alpine skiing accidents from 2000 to 2011 were included. We hypothesized that only patients with clinical suspicion for injuries were admitted for acute CT. RESULTS: Of all acute patients after skiing accidents, 2,252 could be included. From 2000 to 2011, all cerebral injuries and vascular arterial injuries statistically significantly decreased (p < 0.05, respectively). However, extremity fractures, facial fractures, and vertebral fractures increased (p < 0.04, respectively). The number of cerebral hemorrhages, thoracic injuries, and abdominal injuries remained unchanged (p = NS). The mean (SD) number of all initial radiological examinations per victim statistically significantly decreased from 2.3 (0.7) in 2000 to 1.5 (0.6) in 2011, whereas the admissions for acute CT have significantly increased (p < 0.02; respectively). CONCLUSIONS: Acute radiological evaluation in skiing accidents has changed during the last decade. The decrease in overall cerebral injuries might be a function of the increasing use of skiing helmets. A protection of the extremities, trunk, spine, and face, however, needs further improvements and their radiological assessment with CT warrants attention in skiing casualties.

Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries.

OBJECTIVE: The purpose of this retrospective study was to evaluate transcatheter arterial embolization (TAE) for the management of iatrogenic and blunt traumatic intercostal artery (ICA) injuries associated with hemothorax and clinical deterioration. METHODS: From May 1999 through April 2007, 24 consecutive patients (17 men, 7 women; mean age 53 years) presenting with active ICA hemorrhage underwent TAE mainly by means of coils combined with polyvinyl alcohol (PVA) particles. Eleven of them had blunt traumatic injuries (group A, n = 11) and 13 had iatrogenic injuries (group B, n = 13). In all patients, ICA injuries resulted in acute bleeding with clinical deterioration and hemothorax. Before discharge, all patients underwent clinical examination, laboratory tests, and chest x-ray. After discharge, no specific follow-up protocol was required, and the patients were questioned on their state of health at regular intervals and underwent CT or chest x-ray as needed. RESULTS: Primary technical success (PTS) was achieved in 21 of 24 patients (87.5%). In group A, it was achieved in all but one patient (90.9%) and in group B in 11 of 13 patients (84.6%). A total of three patients needed secondary interventions, which failed in one of them, amounting to a secondary technical success rate (STS) of 8.3%. The total cumulative mortality rate was 37.5% (n = 9). In group A, it was 9.1% (n = 1) and in group B, it was 61.5% (n = 8). 30-day-mortality was 9.1% in group A, where one patient died due to multiple severe associated injuries, and 30.8% (n = 4) in group B, where one patient died due to treatment failure and three patients due to severe comorbidities. During follow-up, no more deaths occurred in group A, while in group B, four more patients died due to severe comorbidities, amounting to a late mortality rate of 30.8%. No technical complications and no complications such as chest wall or spinal cord ischemia were observed. The mean observation period was 44.6 months in group A and 23.8 months in group B. CONCLUSION: TAE of ICAs is a minimally invasive, safe, and reliable treatment option to control massive intrathoracic hemorrhage, especially in patients with serious comorbidities and/or multiple injuries. However, it should be performed only by experienced interventionalists and exact knowledge of the anatomic features of the affected artery and of collateral pathways is mandatory to avoid complications.

Serial CT volume and thrombus length measurements after endovascular repair of Stanford type B aortic dissection.

PURPOSE: To evaluate the outcome of stent-graft placement in Stanford type B aortic dissection using contrast-enhanced spiral computed tomographic (CT) measurements of true and false lumen volumes and thrombus length. METHODS: Among 18 consecutive patients (13 men; mean age 60 years, range 44-79) who underwent endovascular repair of Stanford type B dissection, 12 completed at least a 12-month follow-up, which included CT measurements of true and false lumen volumes and thrombus lengths prior to discharge and at 6 and 12 months postimplantation. Volumes were assessed in 3 different aortic segments (A1, A2, A3) extending from the proximal attachment site of the prosthesis to the aortic bifurcation. In addition, thrombus length was measured to evaluate the influence of clot formation on outcome of the false lumen volume. RESULTS: Mean follow-up was 27 months (range 12-60). Within 12 months, mean true lumen volumes showed statistically significant increases in the A1 (p<0.001) and A2 (p=0.003) segments; false lumen volumes showed a significant decrease in the A1 segment (p=0.002) but an insignificant increase in the A2 segment. No substantial volume changes were observed in the A3 segment. Extension of clot formation in the false lumen varied among patients and over time. Length of stent-grafts, percentage of stented dissection length, or visceral arteries originating from the false lumen did not significantly influence thrombus development, nor did these parameters or thrombus formation distal to the prosthesis have a relationship to false lumen volumes. CONCLUSIONS: Volumetric analysis after endovascular repair of Stanford type B dissection shows optimal technical outcome in the stented segment, whereas the false lumen in the segment immediately adjacent to the stent-graft seems to be a vulnerable area. Extension of clot formation beyond the endograft seems to be no reliable predictor of outcome.

Pretransplantation evaluation of the cirrhotic liver with explantation correlation: accuracy of CT arterioportography and digital subtraction hepatic angiography in revealing hepatocellular carcinoma.

OBJECTIVE: The aim of this study was to determine the accuracy of CT arterioportography and hepatic digital subtraction angiography, separately and combined, for the detection of hepatocellular carcinoma in the cirrhotic liver by using thin-section liver explant histopathologic findings. SUBJECTS AND METHODS: Fifty-nine patients with liver cirrhosis were examined with CT arterioportography and digital subtraction angiography as a part of preoperative diagnostic workup for liver transplantation. Before liver explantation, CT arterioportograms and digital subtraction angiograms were prospectively evaluated in a blinded manner, separately by two CT radiologists and two angiographers, respectively, and combined by two reviewer teams, each including a CT radiologist and an angiographer. In addition, each examination was retrospectively evaluated using direct comparison with the corresponding thin-section liver explant specimens RESULTS: There were 39 histologically confirmed hepatocellular carcinomas. In both prospective and retrospective assessments, the reviewers achieved the best performance with CT arterioportography and digital subtraction angiography combined (area under the curve [A(z)] 0.82). The diagnostic confidence in the detection of hepatocellular carcinoma was higher with digital subtraction angiography (A(z), 0.81) than that with CT arterioportography (A(z), 0.68). Prospectively, sensitivity and specificity were 75% and 60% for CT arterioportography, 77% and 80% for digital subtraction angiography, and 84% and 81% for CT arterioportography and digital subtraction angiography combined, respectively. Retrospectively, sensitivity and specificity were 80% and 62% for CT arterioportography; 82% and 79% for digital subtraction angiography; 87% and 81% for CT arterioportography and digital subtraction angiography combined, respectively. Five hepatocellular carcinomas, one poorly and four well differentiated, with a mean size of 1.4 cm were not detectable on the CT arterioportography and digital subtraction angiography combination. False-positive findings were 20, 11, and 10 on CT arterioportography, digital subtraction angiography, and the CT arterioportography and digital subtraction angiography combination. CONCLUSION: Combining CT arterioportography with digital subtraction angiography enabled reliable detectability of moderately and poorly differentiated hepatocellular carcinomas in cirrhotic livers but was less sensitive for the detection of well-differentiated hepatocellular carcinomas and resulted in a relatively high rate of false-positive findings.

Placement of endovascular stent-grafts for emergency treatment of acute disease of the descending thoracic aorta.

OBJECTIVE: The aim of this study was to evaluate the feasibility, safety, and effectiveness of endovascular stent-graft placement for the emergency treatment of acute descending thoracic aortic disease. MATERIALS AND METHODS: From January 1996 through November 2001, 18 patients underwent emergency endovascular stent-graft placement for various types of acute descending thoracic aortic disease. Five patients had Stanford type B aortic dissection, six had traumatic ruptures of the thoracic aorta, five had ruptured aortic aneurysms, and two had penetrating atherosclerotic aortic ulcers. All patients presented with life-threatening symptoms requiring treatment with stent-grafts from the emergency kit. All were at high surgical risk due to serious comorbidities. The efficacy of the procedure was assessed at follow-up studies before discharge and at 3, 6, and 12 months after intervention and yearly thereafter. RESULTS: The primary technical success rate was 78%. Four patients had primary perigraft leaks. The secondary technical success rate was 83%. One patient died 20 hr after intervention from stent-graft-related causes. Follow-up studies revealed stent-graft migration in one patient. Progression of disease was observed in one patient treated for dissection and in both patients treated for penetrating ulcers. One patient died 7 months after intervention of unknown reasons; all other patients are alive. The mean follow-up time was 17.4 months (range, 0-38 months). CONCLUSION: Emergency repair of acute descending thoracic aortic disease with stent-graft placement can be successfully accomplished and may be a promising alternative to open-chest surgery, especially in patients at high risk.