Blunt Traumatic Aortic Injury In The Elderly Population
Patricia O. Yau, MD, Richard Teo, MD, Erin Lewis, MD, Amit Shah, MD, Melvin Stone, MD, Aksim Rivera, MD.
Jacobi Medical Center, Bronx, NY, USA.
OBJECTIVES: Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. While outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database.
METHODS: Patients aged 65 years and older with BTAI from 2007-2016 were identified from the National Trauma Data Bank. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management.
RESULTS: During the study period, 1322 patients aged 65 and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There was low incidence of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management (Figure). Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model controlling for age, race, gender, ISS and hypotension, TEVAR was associated with the lowest mortality rate (1.24 deaths/100 person-years, CI: 0.98-1.57) compared with open repair (2.73, CI: 1.76-4.23, p=.001) and nonoperative management (4.12, CI: 3.56-4.78, p<.001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group.
CONCLUSIONS: This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients were unable to undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared to open repair and nonoperative management.
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