Evaluation of a Standardized Severity Grading System for Blunt Thoracic Aortic Injury in the Endovascular Era: A Retrospective Review from a Level I Trauma Center

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for giving me the opportunity

Congratulations, on the hard work put into this manuscript

Two comments

In terms of the Results section, 

18 patients underwent non operative management, 10 underwent repeat CT scan is there a particular reason with regards to the surveillance scan. If yes, can we please include the details with regards to same in the section. Was this dependant on the interventional service? Is there a pathway for this injury management at the author's institute. If yes, can the pathway be added as a supplement to this manuscript?

Grade II injuries, 20% still received an intervention, though the guidelines state that grade 2 do not require any intervention. If this was personal dependant, then we should have a mention in the limitations section.

For grade 3, 18% non-operative, did this cohort have a surveillance scan to support management of the same without intervention as majority 82% received an intervention.

I am comfortable to re review if the authors are happy to make the changes

All the best

 

 

Author Response

1. R1 -- 18 patients underwent non operative management, 10 underwent repeat CT scan is there a particular reason with regards to the surveillance scan. If yes, can we please include the details with regards to same in the section. Was this dependant on the interventional service? Is there a pathway for this injury management at the author's institute. If yes, can the pathway be added as a supplement to this manuscript? There is no protocolized pathway and care plan was determined by each individual vascular surgeon. (p9, p11)

2. R1 -- Grade II injuries, 20% still received an intervention, though the guidelines state that grade 2 do not require any intervention. If this was personal dependant, then we should have a mention in the limitations section. This was dependent on individual vascular surgeon’s review of imaging. (p9, p11)

3. R1 -- For grade 3, 18% non-operative, did this cohort have a surveillance scan to support management of the same without intervention as majority 82% received an intervention. Yes - 1 declined surgery/imaging, 1 had care withdrawn (i.e., “comfort care”), and the remaining underwent surveillance CTs. (p9)

Reviewer 2 Report

Comments and Suggestions for Authors

This retrospective review seeks to explore the association of TAI severity with presentation patterns, outcomes and interventions. The key message that the SVS 4 grade severity system is still useful in guiding clinical decision making for TAI.

Strengths: Adds to the data of a relatively uncommon injury. Adds strength to back the continued use of the current grading system.

Weaknesses: Single center retrospective review study.

Overall: Interesting study that tries to look whether the current grading system, which is over a decade old, is still relevant with the changing landscape of vascular intervention.

Comments:

1. P7L168-182 – Authors mentioned 18 patients had non-operative management. I understand the grade 1 and 4, but why did 11 patients (other than the one who declined) not have operative management? Were these before or after the 2011 SVS recommendations? Would the temporal shift in management after the guidelines came out have altered the results?
2. P8 Table 2 - Was there a reason why the grade 1 patients had the longest stay overall?

Author Response

1. R2 -- P7 L168-182 – Authors mentioned 18 patients had non-operative management. I understand the grade 1 and 4, but why did 11 patients (other than the one who declined) not have operative management? Were these before or after the 2011 SVS recommendations? Would the temporal shift in management after the guidelines came out have altered the results? Similar to comments 1-2, this was surgeon-dependent based on review of imaging. Although not 100% of G2 underwent nonoperative management, and not 100% of G3 underwent operative management, the associations were still significant. I believe this comment is more about the decision-making for the 11 G2s and 5 G3s that did not undergo operative intervention. Those 16 either expired, declined OR, were diagnosed later into their admission ("aging out" of the window of showing clinical stability), or had a surveillance CT instead of operative management, based on surgeon discretion. (p9)
2. R2 -- P8 Table 2 - Was there a reason why the grade 1 patients had the longest stay overall? The associations in LOS with grade of aortic injury were not statistically significant, but were related to concomitant injuries and/or disposition/awaiting post-hospital placement. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for making the appropriate changes

I have no further comments

Reviewer 2 Report

Comments and Suggestions for Authors

all comments addressed