Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO
as a proxy for PaCO
. We ...assessed whether the difference between end tidal CO
and PaCO
at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO
gap-defined as the difference between end tidal CO
and PaCO
-and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO
gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO
and PaCO
at admission was low (Pearson's r = .287). The mean CO
gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO
gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO
gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO
and PaCO
is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO
was significantly lower than PaCO
, making it an unreliable proxy for PaCO
when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.
We evaluated the long-term morphologic and clinical outcomes after thoracic endovascular aortic repair combined with parallel grafts (PG-TEVAR) for arch-involving aortic pathologies.
We performed a ...retrospective analysis of perioperative and follow-up data of patients who had undergone PG-TEVAR at a single vascular surgery center from November 2010 to April 2018. Patients with prior or simultaneous open chest or cervical debranching procedures or arch repair were excluded. The primary endpoint was freedom from overall PG-TEVAR–related reintervention. The secondary endpoints were parallel graft sealing zone failure (presence of gutter-related type I or Ic endoleak), PG failure (occlusion or reintervention), stroke, and 30-day and overall PG-TEVAR–related and all-cause mortality. Kaplan-Meier curves were used to estimate the freedom from reintervention and survival. Receiver operating characteristics curves were used to find the optimal cutoff to prevent type Ia endoleak-related reintervention.
A total of 33 patients, including 8 women, with a median age of 74 years (interquartile range, 67-79 years) had undergone PG-TEVAR (chimney, periscope, and sandwich in 20, 15, and 13 patients, respectively) with proximal landing in Ishimaru zone 0, 1, or 2 in 4, 5, and 24 patients, respectively. The aortic pathologies included type B aortic dissection (acute and chronic, eight and six, respectively), degenerative aneurysm (n = 10), type Ia endoleak (n = 3), para-anastomotic/patch aneurysm (n = 4), left subclavian artery aneurysm (n = 1), and traumatic rupture (n = 1). The perioperative stroke rate and 30-day mortality was 6% and 9%, respectively. Direct postoperative computed tomography revealed 28 endoleaks (gutter-related type Ia, 12; gutter-related type Ib, 9; type Ia, 2; type Ic, 2; type III, 1; undetermined, 2) in 27 patients. The technical and clinical success rate was 37% and 30%, respectively. The mean follow-up for survival was 48 ± 31 months. The latest radiologic follow-up demonstrated 12 remaining and 1 new endoleak. The early and overall PG sealing zone failure and PG failure was 73% and 36% and 9% and 18%, respectively. The overall PG-TEVAR–related reintervention rate was 33% (n = 11). The estimated freedom from overall PG-TEVAR–related reintervention was 68% at 60 months. The main graft oversizing and length oversizing rates were not significantly associated statistically with the type Ia endoleak-related reintervention rate. The PG-TEVAR–related and all-cause mortality were 18% and 34%, respectively.
PG-TEVAR for total endovascular repair of arch-involving aortic pathologies resulted in a high rate of type I endoleaks and the need for long-term reintervention. Gutter-related endoleaks might be more frequent than reported and should not be underestimated because they can lead to sac enlargement and reintervention. Frequent radiologic surveillance is mandatory. Further studies comparing PG-TEVAR to other total endovascular alternatives are required to confirm these findings.
The incidence of type A aortic dissection (TAAD) has increased in several countries in recent decades, but epidemiological data for Switzerland are lacking. Furthermore, there are conflicting data ...regarding a gender-disparity with higher type A aortic dissection mortality in women. This study analysed sex-specific hospital incidence and in-hospital mortality rates of TAAD in Switzerland.
This study is a secondary data analysis of case-related hospital discharge data from the Swiss Federal Statistical Office for 2009-2018. Cases that were hospitalised and surgically treated for type A aortic dissection were included in this analysis. Standardised incidence rates were calculated using the European standard population in 2013. All-cause in-hospital mortality rates were calculated as raw values and standardised for age, sex, and the van Walraven comorbidity score.
A total of 2117 participants were included in this study, of whom 67.1% were male. The age-standardised cumulative hospital incidence for type A aortic dissection treatment was 3.5 per 100,000 (95% CI: 3.3-3.7) for men and 1.7 (1.6-1.8) per 100,000 for women (p <0.001). The incidence rates increased in both sexes during the observed decade. The adjusted mortality rates for treatment of TAAD decreased from 27.6% (26.7-28.5%) in 2009 to 18.5% (17.9-19.1%) in 2018 in women, and they decreased from 19.0% (18.4-19.6%) to 12.3% (11.9-12.7%) in the same period in men. Multivariable logistic regression analysis revealed that female sex was significantly associated with higher mortality, with an odds ratio of 1.39 (1.07-1.79) (p = 0.012).
Hospital incidence rates for the treatment of type A aortic dissection increased in both sexes over the observed decade. The mortality rate was significantly higher in women than it was in men, but it decreased in both sexes. TAAD remains a cardiovascular emergency with a high mortality rate even after emergency surgery.
Purpose.
The treatment of infectious aortic disease is still challenging with open surgical debridement and reconstruction using biological, preferably autologous material, being the treatment of ...choice. However, these procedures are associated with high morbidity and mortality. Endovascular therapy is often considered a bridging method only, since the biologically inactive fabric of the covered stent grafts usually cannot be treated sufficiently with anti-infective agents in the event of a (obligate) consecutive secondary graft infection. This study aims to prove the feasibility of a physician-made pericardium stent graft ex-vivo.
Technique.
A state-of-the-art TEVAR was modified by separating the fabric from the z-stents and suturing a hand-sewn bovine pericardium tube to the bare metal. Feasibility of preparation, re-sheathing, and delivery is demonstrated in an ex-vivo model.
Conclusion.
This first xenogeneic stent graft could be manufactured and deployed successfully. In the future this may provide a bridging alternative for high-risk patients with infected native aortic aneurysm or aortic fistulas, eventually followed by surgical or thoracoscopic/laparoscopic debridement. Further studies on simulators or animal models are needed to test the technique and investigate its long-term durability. Additionally, this study prompts reflection on whether materials currently used should be further developed to prevent graft infections.
The role of endovascular aneurysm repair (EVAR) in patients with asymptomatic abdominal aortic aneurysm (AAA) who are unfit for open surgical repair has been questioned. The impending risk of ...aneurysm rupture, the risk of elective repair, and the life expectancy must be balanced when considering elective AAA repair. This retrospective observational cohort study included all consecutive patients treated with standard EVAR for AAA at a referral centre between 2001 and 2020. A previously published predictive model for survival after EVAR in patients treated between 2001 and 2012 was temporally validated using patients treated at the same institution between 2013 and 2020 and updated using the overall cohort. 558 patients (91.2% males, mean age 74.9 years) were included. Older age, lower eGFR, and COPD were independent predictors for impaired survival. A risk score showed good discrimination between four risk groups (Harrel's C = 0.70). The 5-years survival probabilities were only 40% in "high-risk" patients, 68% in "moderate-to-high-risk" patients, 83% in "low-to-moderate-risk", and 89% in "low-risk" patients. Low-risk patients with a favourable life expectancy are likely to benefit from EVAR, while high-risk patients with a short life expectancy may not benefit from EVAR at the current diameter threshold.
Purpose: To compare open versus endovascular left subclavian artery debranching for thoracic endovascular aortic repair of thoracic aortic pathologies.Methods: This is a retrospective study of ...patients receiving left subclavian artery debranching in our institution from October 2009 to January 2020. The primary outcome was freedom from aortic reintervention. Secondary outcomes were type I endoleaks, left subclavian artery (LSA) debranching failure, stroke, technical or clinical success, procedure-related reintervention, as well as 30-day or overall all-cause and aorta-related mortality.Results: Forty-eight patients received parallel graft-based (n = 24, ENDO; median age 75 years 70–80 years) or open (n = 24, OPEN; median age 71 years 59–75 years) debranching for type B aortic dissection (n = 25), degenerative aneurysm (n = 12), type IA endoleak (n = 6), suture-associated (n = 3) or ostial LSA aneurysm (n = 1), or penetrating aortic ulcer (n = 1). The median follow-up was 36 months (13–61 months). After 16 months, aortic reintervention-free survival in groups OPEN and ENDO was 91% (95% confidence interval CI: 79 to 100%) and 86% (73 to 100%) (p = 0.71), respectively. After 36 months, all-cause survival in groups OPEN and ENDO was 74% (95% CI: 55 to 99%) and 79% (95% CI: 64 to 97%) (p = 0.74), respectively; freedom from aorta-related mortality was 81% (95% CI: 62 to 100%) and 91% (95% CI: 80 to 100%) (p = 0.78), respectively. Group OPEN presented less type I endoleaks (OPEN/ENDO = 3/19, p <0.001) and higher technical (OPEN/ENDO = 81/36%, p = 0.003) and clinical success rates (OPEN/ENDO = 67/36%, p = 0.047). No statistical differences were found for other outcomes.Conclusion: Both strategies achieved comparable reintervention and mortality rates, but open debranching should be preferred due to its higher technical and clinical success and less type I endoleaks.
AIM OF THE STUDY: To analyse hospital incidence and in-hospital mortality of patients treated for abdominal aortic aneurysms in Switzerland.
METHODS: Secondary data analysis of case-related hospital ...discharge data of the Swiss Federal Statistical Office for the years 2009–2018. Patients who were hospitalised and surgically treated for nonruptured abdominal aortic aneurysms or hospitalised and treated for ruptured abdominal aortic aneurysms were included in the analysis. Standardised annual incidences rates were calculated using the European standard population 2013. In-hospital all-cause mortality rates were calculated as raw values and standardised for age, sex, and the van Walraven comorbidity score.
RESULTS: A total of 10,728 cases were included in this study, of which 87.1% were male. Overall, 22.7% of the patients presented with a ruptured abdominal aortic aneurysm; 46% of these cases were surgically treated whereas 54% received conservative therapy. The age-standardised cumulative hospital incidences for treatment of nonruptured abdominal aortic aneurysms were 2.6 (95% confidence interval 2.5–2.8) and 19.7 (19.2–20.1) per 100,000 for women and men, respectively; for ruptured aneurysms it was 0.4 (0.3–2.4) per 100,000 in women, and 2.7 (2.6–2.9) in men. The annual incidence rates were stable in the decade observed. The adjusted mortality rates for treatment of nonruptured aneurysms decreased from 5.5% (2.6–11.2%) in 2009 to 1.4% (0.5–3.6%) in 2018 in women, and from 2.4% (1.3–4.5%) in 2009 to 0.6% (0.2–1.5%) in 2018 in men. The adjusted mortality rates for treatment of ruptured abdominal aortic aneurysms remained high without relevant improvements for either sex over time: for women 32.4% (24.1–42.1%), for men 19.7% (16.8–22.8%).
CONCLUSIONS: The hospital incidence rates for nonruptured and ruptured abdominal aortic aneurysms remained unchanged in the decade observed. Compared with Germany, there was no evidence for a decrease in the annual incidence rates for ruptured abdominal aortic aneurysms in Switzerland. Mortality rates in the elective setting were low and decreased in the last decade but remained high in patients treated for ruptured aneurysms. Efforts to reduce the incidence of ruptured abdominal aortic aneurysms are needed to reduce aneurysm-related mortality in Switzerland.
The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This ...study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland.
This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland's largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated.
A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km.
Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain.
Background Traumatic brain injury (TBI) remains one of the main causes of mortality and long-term disability worldwide. Maintaining physiology of brain tissue to the greatest extent possible through ...optimal management of blood pressure, airway, ventilation, and oxygenation, improves patient outcome. We studied the quality of prehospital care in severe TBI patients by analyzing adherence to recommended target ranges for ventilation and blood pressure, prehospital time expenditure, and their effect on mortality, as well as quality of prehospital ventilation assessed by arterial partial pressure of CO.sub.2 (PaCO.sub.2) at hospital admission. Methods This is a retrospective cohort study of all TBI patients requiring tracheal intubation on scene who were transported to one of two major level 1 trauma centers in Switzerland between January 2014 and December 2019 by Swiss Air Rescue (Rega). We assessed systolic blood pressure (SBP), end-tidal partial pressure of CO.sub.2 (PetCO.sub.2), and PaCO.sub.2 at hospital admission as well as prehospital and on-scene time. Quality markers of prehospital care (PetCO.sub.2, SBP, prehospital times) and prehospital ventilation (PaCO.sub.2) are presented as descriptive analysis. Effect on mortality was calculated by multivariable regression analysis and a logistic general additive model. Results Of 557 patients after exclusions, 308 were analyzed. Adherence to blood pressure recommendations was 89%. According to PetCO.sub.2, 45% were normoventilated, and 29% had a SBP greater than or equal to 90 mm Hg and were normoventilated. Due to the poor correlation between PaCO.sub.2 and PetCO.sub.2, only 33% were normocapnic at hospital admission. Normocapnia at hospital admission was strongly associated with reduced probability of mortality. Prehospital and on-scene times had no impact on mortality. Conclusions PaCO.sub.2 at hospital admission is strongly associated with mortality risk, but normocapnia is achieved only in a minority of patients. Therefore, the time required for placement of an arterial cannula and prehospital blood gas analysis may be warranted in severe TBI patients requiring on-scene tracheal intubation. Keywords: Prehospital emergency medicine, HEMS, Traumatic brain injury, Tracheal intubation, Ventilation
: Aneurysms and dissections of the iliac artery (ADIAs) are significant vascular conditions often associated with aortic pathologies. Despite their importance, reports on isolated iliac artery ...pathologies are rare. This study aimed to investigate the epidemiology of ADIA in Switzerland including treatment incidence and hospital outcomes.
: A retrospective analysis of diagnosis-related group (DRG) statistics from 2011 to 2018 in Switzerland was conducted, identifying all cases of ADIA while excluding those with concomitant treatment of aortic pathologies. Age-standardized incidence rates and treatment outcomes were assessed, with multivariable logistic regression performed to identify factors associated with hospital mortality.
: From 2011 to 2018, 1037 ADIA cases were hospitalized in Switzerland. Incidence rates for elective treatment were significantly higher in men than women, increasing in men from 1.5 to 2.4 cases per 100,000 men (
= 0.007), while remaining stable in women at around 0.2 cases per 100,000 women. Acute treatment incidence rates were lower but still higher in men, at 0.9 cases per 100,000 men and 0.2 cases per 100,000 women. Crude hospital mortality rates were lower for endovascular repair than open surgical repair in both elective (0.8% vs. 3.1%,
= 0.023) and emergency treatment (6.7% vs. 18.4%,
= 0.045). Multivariable analysis showed that endovascular repair was associated with significantly reduced hospital mortality compared to open repair (OR 0.27, 95%-CI: 0.10 to 0.66,
= 0.006).
: This nationwide study of iliac artery pathologies shows that the treatment incidence was about 10 times higher in men than in women for elective procedures, but only about five times higher for emergency treatment. Endovascular procedures were associated with significantly lower hospital mortality than open procedures, while hospital mortality rates were comparable for men and women.
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