Penetrating thoracic great vessel injury: impact of admission hemodynamics and preoperative imaging.
BACKGROUND
The management of penetrating great vessel (PGV) injury is challenging. Patients in shock require rapid evaluation, whereas in stable patients, imaging studies may optimize the surgical approach. We reviewed our experience with PGV injury to determine the impact of admission blood pressure and accuracy of imaging studies, both angiography and computed tomographic angiography (CTA).


METHODS
Retrospective review of the trauma registry from 2001 to 2007 identifying patients with PGV injury. Demographics, admission systolic blood pressure, imaging studies, specific injuries, incision, methods of repair, hospital and intensive care length of stay, complications, and mortality were recorded. Shock was defined as systolic blood pressure <90 mm Hg.


RESULTS
Thirty-six consecutive patients were identified, average age was 28 (+/-10) years, of whom 20 (56%) presented in shock. Those in shock had more combined arterial-venous injuries (60% vs. 25%), concomitant thoracic injuries requiring resection (45% vs. 19%), and units of packed red blood cells (5.8 +/- 2 vs. 2.7 +/- 1.5), p < 0.01. For those in shock, the mean time to the operating room was 27 minutes +/- 9 minutes and 75% had sternotomy. Among stable patients, 56% had a periclavicular approach and 31% partial sternotomy. All 16 stable patients had imaging; angiography in 3 patients and CTA in 7 patients. In six patients who had both angiography and CTA, the results were concordant; therefore, CTA accurately diagnosed arterial injury in all 13 patients. Imaging changed the choice of incision in 4 (25%). Intensive care length of stay was significantly longer in the shock group 3.1 (+/-2.1) days versus 1.4 (+/-1.6) days (p = 0.01). There were 5 (14%) complications and no deaths.


CONCLUSIONS
Patients in shock require rapid evaluation. Sternotomy affords excellent exposure to all PGV injuries, and partial sternotomy is useful in stable patients. In stable patients, CTA can be valuable in defining the injury and may influence the surgical approach. Surgical results are surprisingly good, even in unstable patients and may be related to rapid transport and operation.
O'Connor
James V
JV
R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA. joconnor@umm.edu
Scalea
Thomas M
TM
D000293:Adolescent; D000328:Adult; D000792:Angiography; D001808:Blood Vessels / Q000293:injuries*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012042:Registries; D012189:Retrospective Studies; D056346:Sternotomy; D013898:Thoracic Injuries / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000601:surgery*; D013909:Thorax / Q000098:blood supply*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000601:surgery*; D014951:Wounds, Stab / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000601:surgery*