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Letters to the Editor |
b
a Department of Thoracic Surgery, University Hospital "Sestre milosrdnice", Zagreb, Croatia
b Department of Endo and Vascular Surgery, University Hospital "Sestre milosrdnice", Zagreb, Croatia
Received 6 February 2008; accepted 30 April 2008.
* Corresponding author. Address: University Department of Surgery, University Hospital ‘Sestre milosrdnice’, 10000, Vinogradska 29, Zagreb, Croatia. Tel.: +385 1 37 87 404; fax: +385 1 38 62 292. (Email: borki.vucetic{at}zg.htnet.hr).
Key Words: Traumatic aortic rupture • Endovascular repair • Asymptomatic patients
The article by Buz and associates [1] calls attention to the possibility of an endovascular treatment of traumatic aortic rupture.
This policy may have a strong impact on mortality and morbidity rates that are usually very high in this condition, considering a conventional surgical approach. The obtained results [30-day mortality rate in conventional surgical group 20% (7 of 35), vs endovascular group 7.7% (3 of 39); complication rate (28.5% vs 3%); and survival rate (75% vs 86.4–81.6%)] were due to severely compromised clinical status preoperatively, and it seems fair to assume that conventional surgery would have much higher risk or would not be considered.
Despite the fact that a recent report [1] represents the largest series to date [2], similar results have been described in the literature by other authors as well [3–5].
However, none of the other previously published studies compared a cohort of patients treated within a defined period of time by either endovascular or conventional surgical means, undergoing the same preoperative workup and resuscitation protocol, as well as postoperative care by the same team.
From that point of view, the authors overcame the previously published reports and covered almost all criteria of contemporary knowledge about open surgical repair (OSR) and thoracic endovascular aortic repair (TEVAR) of acute traumatic aortic rupture (ATAR).
On the other hand, critical areas of OSR/TEVAR management where the knowledge is still insufficient are missing.
So by way of a swansong we would like to propose to the authors why they might want to take further advice on investigation of OSR and TEVAR of ATAR.
Investigations of OSR or TEVAR for treatment of symptomatic patients with ATAR are not definitive solutions and must include detection of asymptomatic patients.
More precise detection of clinical parameters in asymptomatic patients (delayed rupture) as an attempt to elucidate whether a number of potential TEVAR beneficial changes exists were not noted and advocated by authors, and these could result in a significant change in management and outcome in other institutions.
There is still debate about whether angiography or CT-angiography should be the first test, and the authors did not re-evaluate current preoperative protocols and offered preferred solutions for the recognition of indications for delaying operative interventions in asymptomatic patients.
In every-day practice, the detection of the earliest stages of ATAR before the onset of symptoms, followed by prompt treatment, might postpone death, but of course not prevent death.
Not all patients are anatomically suitable for stent grafts and additional information of anatomic prerequisites related to TEVAR and stock of stent grafts in the hospital could be helpful. This is mainly because of the fact that some stent graft sizes are not always available within the hospital, and need to be ordered from the company.
With the development of evidence based medicine (EBM) in cardiovascular surgery, we can do this with increasing precision and individualization.
In addition, we need to be confident that the opportunity costs of TEVAR do not consume too many resources as to threaten the funding for treatment and cure of symptomatic disease.
References
This article has been cited by other articles:
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  L. K. von Segesser Clinical databases - a double-edged sword! Eur. J. Cardiothorac. Surg., May 1, 2009; 35(5): 749 - 750. [Full Text] [PDF]
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S. Buz, B. Zipfel, and R. Hetzer Reply to vucetic et Al. Eur. J. Cardiothorac. Surg., August 1, 2008; 34(2): 470 - 471. [Full Text] [PDF]
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