Outcomes of Operative and Non-Operative Management in Blunt Thoracic Aortic Injury

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Research progress on quercetin in improving the survival rate of random skin flap

Random skin flap transplantation is critical in wound repair, organ reconstruction and cosmetic surgery, yet skin flap necrosis remains a common and challenging issue. Quercetin, a flavonoid abundant in various plants, exhibits anti-inflammatory, antioxidant, and other beneficial pharmacological effects. Recent studies suggest quercetin can improve random skin flap survival by modulating inflammation, reducing oxidative stress, and promoting angiogenesis. This review evaluates quercetin's potential mechanisms and efficacy, proposing a foundation for its clinical use in preventing ischemic necrosis and enhancing flap viability.

Effects of Timing of Repair on Mortality Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

BACKGROUND

Blunt thoracic aortic injuries (BTAIs) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated.

METHODS

All patients with Grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multicenter registry from 2015 to 2022 were categorized dependent on timing of repair (early repair [ER] < 24 hours, late repair > 24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality.

RESULTS

Two hundred and twenty two Grade 2 and 3 BTAI treated by TEVAR were analyzed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale, age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. Thirty-day in-hospital mortality occurred in 14 patients (6%), 2 of which were aortic-related. Thirty-day mortality was associated with a higher baseline incidence of coronary artery disease/peripheral vascular disease/previous cardiac revascularization; lower systolic blood pressure, Glasgow Coma Scale, hemoglobin, platelet count, and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower hemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (P < 0.05), although time to TEVAR was not.

CONCLUSIONS

In selected patients, delay in performance of TEVAR for Grade 2 and 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury

BACKGROUND

Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury.

METHODS

A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

RESULTS

Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8).

CONCLUSIONS

Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.

Outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury stratified by Society for Vascular Surgery grade

OBJECTIVES

Although the Society for Vascular Surgery (SVS) aortic injury grading system is used to depict the severity of injury in patients with blunt thoracic aortic injury, prior literature on its association with outcomes after thoracic endovascular aortic repair (TEVAR) is limited.

METHODS

We identified patients undergoing TEVAR for BTAI within the VQI between 2013 and 2022. We stratified patients based on their SVS aortic injury grade (grade 1, intimal tear; grade 2, intramural hematoma; grade 3, pseudoaneurysm; and grade 4, transection or extravasation). We assessed perioperative outcomes and 5-year mortality using multivariable logistic and Cox regression analyses. Secondarily, we assessed the proportional trends in patients undergoing TEVAR based on SVS aortic injury grade over time.

RESULTS

Overall, 1311 patients were included (grade1, 8%; grade 2, 19%; grade 3, 57%; grade 4, 17%). Baseline characteristics were similar, except for a higher prevalence of renal dysfunction, severe chest injury (Abbreviated Injury Score >3), and lower Glasgow Coma Scale with increasing aortic injury grade (Ptrend < .05). Rates of perioperative mortality by aortic injury grade were as follows: grade 1, 6.6%; grade 2, 4.9%; grade 3, 7.2%; and grade 4, 14% (Ptrend = .003) and 5-year mortality rates were 11% for grade 1, 10% for grade 2, 11% for grade 3, and 19% for grade 4 (P = .004). Patients with grade 1 injury had a high rate of spinal cord ischemia (2.8% vs grade 2, 0.40% vs grade 3, 0.40% vs grade 4, 2.7%; P = .008). After risk adjustment, there was no association between aortic injury grade and perioperative mortality (grade 4 vs grade 1, odds ratio, 1.3; 95% confidence interval, 0.50-3.5; P = .65), or 5-year mortality (grade 4 vs grade 1, hazard ratio, 1.1; 95% confidence interval, 0.52-2.30; P = .82). Although there was a trend for decrease in the proportion of patients undergoing TEVAR with a grade 2 BTAI (22% to 14%; Ptrend = .084), the proportion for grade 1 injury remained unchanged over time (6.0% to 5.1%; Ptrend = .69).

CONCLUSIONS

After TEVAR for BTAI, there was higher perioperative and 5-year mortality in patients with grade 4 BTAI. However, after risk adjustment, there was no association between SVS aortic injury grade and perioperative and 5-year mortality in patients undergoing TEVAR for BTAI. More than 5% of patients with BTAI who underwent TEVAR had a grade 1 injury, with a concerning rate of spinal cord ischemia potentially attributable to TEVAR, and this proportion did not decrease over time. Further efforts should focus on enabling careful selection of patients with BTAI who will experience more benefit than harm from operative repair and preventing the inadvertent use of TEVAR in low-grade injuries.

Trends and Outcomes in Management of Thoracic Aortic Injury in Children, Adolescent, and Mature Pediatric Patients Using Data from the National Trauma Data Bank

BACKGROUND

Thoracic aortic injury (TAI) is rare in the pediatric population. Thoracic endovascular aortic repair (TEVAR) is the recommended standard of care for treatment in the adult population given its association with lower rates of mortality and morbidity than traditional open repairs for treatment of TAI. However, there are unique anatomic challenges in treating pediatric patients with TEVAR which may impact the outcomes and pediatric guidelines. We aimed to compare current management trends and outcomes between different pediatric age groups using data from the National Trauma Data Bank (NTDB).

METHODS

We analyzed the NTDB from 2007 to 2019 using International Classification of Diseases (ICD)-9 and -10 codes to identify patients with a TAI. We excluded patients older than 21 years and any patients who died in the emergency department. The pediatric patients were stratified by age group: children (1-11 years), adolescent (12-17 years), and mature (18-21 years) patients. Patient characteristics compared included injury mechanism and severity, TAI intervention, and outcomes between the 3 groups using bivariate analysis (analysis of variance for parametric and Kruskal-Wallis for nonparametric variables). These characteristics and outcomes were also compared by TAI intervention and injury mechanism. ICD-9 and -10 procedural codes were used to identify patients who underwent TEVAR, open aortic repair (OAR), or both. The modified Poisson regression was performed with relative risk (RR) to evaluate our primary outcome measure-mortality during the trauma admission.

RESULTS

A total of 2,431 pediatric TAI were identified in the NTDB that met the inclusion criteria. This included 134 children (5.5%), 733 adolescent (30.2%), and 1,564 mature (64.3%) patients. Children had significantly lower median Injury Severity Scores (34.1) than the adolescent (38) or mature population (36.1) (P = 0.001). The mechanism of injury differed between age groups. Children had higher rates of blunt trauma (90.3% children, 89.6% adolescent, and 86.8% mature patients) and mature patients had higher rates of penetrating trauma (6% children, 10.1% adolescent, and 12.5% mature patients) (P < 0.001). TAI management also differed significantly between pediatric age groups. Mature patients had significantly higher rates of TEVAR (3% children, 25.2% adolescent, and 29.2% mature patients) and children were most likely to be treated with nonoperative management (NOM) (94% children, 67.9% adolescent, and 64.8% mature patients) (P < 0.001). Patients who were treated with TEVAR were discharge home most frequently (31.8% NOM, 54.1% TEVAR, 44.3% OAR, 22.2% both TEVAR and OAR). Upon modified Poisson regression analysis, patient age was not associated with an increased risk of in-hospital mortality. Intervention with TEVAR (RR: 0.22, 95% CI: 0.15-0.33, P < 0.001) and OAR (RR: 0.58, 95% CI: 0.36-0.93, P = 0.024) were associated with a lower risk of mortality than NOM.

CONCLUSIONS

TAI is less prevalent in children compared to adults. TEVAR for TAI is associated with lower risk of in-hospital mortality compared to both NOM and OAR without differences between pediatric subgroups. Further studies should be completed to determine the most appropriate management guidelines.

Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis

BACKGROUND

Approximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment. This study analyzed and reported the treatment strategy of a single center for BTAI in the last 10 years and the early and middle clinical results.

METHODS

This retrospective study included patients diagnosed with BTAI at Xijing Hospital from 2013 to 2022. All inpatients with BTAI aged ≥ 18 years were included in this study. The clinical data, imaging findings, and follow-up results were retrospectively collected and analyzed. The Kaplan-Meier curve and multivariate logistic regression were used to compare survivors and nonsurvivors.

RESULTS

A total of 72 patients (57% men) were diagnosed with BTAI, with a mean age of 54.2 ± 9.1 years. The injury severity score was 24.3 ± 18, with Grade I BTAI1 (1.4%), Grade II 17 (23.6%), Grade III 52 (72.2%), and Grade IV 2 (2.8%) aortic injuries. Traffic accidents were the main cause of BTAI in 32 patients (44.4%). Most patients had trauma, 37 had rib fractures (51.4%), Sixty patients (83.3%) underwent thoracic endovascular aortic repair (TEVAR) surgery, eight (11.1%) underwent conservative treatment, and only four (5.6%) underwent open surgery. The overall hospitalization mortality was 12.5%. In multivariate logistic regression, elevated creatinine levels (P = 0.041) and high Glasgow coma scale (GCS) score (P = 0.004) were the predictors of hospital mortality. The median follow-up period was 57 (28-87) months. During the follow-up period, all-cause mortality was 5.6% and no aortic-related deaths were reported. Three patients (4.2%) needed secondary surgery and two of them underwent endovascular repair.

CONCLUSION

Although TEVAR surgery may be associated with intra- or postoperative dissection rupture or serious complications in the treatment of Grade III BTAI, the incidence rate was only 8.9%. Nevertheless, TEVAR surgery remains a safe and feasible approach for the treatment of Grade II or III BTAI, and surgical treatment should be considered first,. A high GCS score and elevated creatinine levels in the emergency department were closely associated with hospital mortality. Younger patients need long-term follow-up after TEVAR.

Blunt traumatic aortic injury to the brachiocephalic and left carotid arteries

BACKGROUND

Blunt traumatic aortic injury (BTAI) is a life-threatening pathology that most commonly occurs after traffic accidents or a fall from a considerable height. We report a rare case of traumatic double transection which included the brachiocephalic artery (BCA) and left carotid artery (LCA) following a motorcycle accident.

CASE PRESENTATION

A 52-year-old man was brought to our emergency room for blunt trauma. Urgent computed tomography (CT) indicated BCA and LCA transection. Two weeks after the BTAI, CT indicated an increase in the size of the BCA pseudoaneurysm, a newly developed LCA pseudoaneurysm, and a spread of hematoma. An emergency partial aortic arch replacement including BCA and LCA reconstruction was performed 17 days after the BTAI. The postoperative course was good, and he was discharged 12 days later.

CONCLUSIONS

An open aortic repair appeared to be more suited in the present case because the aortic injury occurred in a branched lesion of the aortic arch. It was thought that complete stent graft coverage of the transection lesion would be difficult. Although coexisting multiple system injuries complicate aortic repair, there was a rapid enlargement of the BCA and LCA pseudoaneurysms. Therefore, strict management is needed even in the case of cervical artery injury.