Management and In-hospital Mortality of 2235 Patients With a Traumatic Intimal Tear of the Thoracic Aorta

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis

OBJECTIVE

We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration.

BACKGROUND

Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking.

METHODS

Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification.

RESULTS

Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group.

CONCLUSION

In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Coil Embolization of Post-Traumatic Pseudoaneurysm of the Ascending Aorta

BACKGROUND Traumatic rupture of the ascending aorta is a life-threatening injury, with a survival rate of around 15% to 20%. Treatment with open surgical repair is the criterion standard. However, open surgical repair is associated with high mortality and morbidity in patients with multiple traumas. There are no systematic data on traumatic thoracic rupture and aorta rupture in a cohort of patients who had undergone partial or total replacement of the thoracic aorta. We can only speculate about the mechanisms and consequences of such an injury. Therefore, even unorthodox endovascular techniques are a welcome advancement in this field and should be considered, providing they do not compromise patient safety. CASE REPORT A 61-year-old man presented with polytrauma after a fall from height. Since the patient had a history of a Bentall procedure, hypertension, coronary disease, and nicotinism, we quickly excluded open surgery as a treatment option. However, the patient's condition, additional injuries, and anatomical features prompted us to perform coil pseudoaneurysm, reducing his operative trauma and allowing for his faster recovery and early rehabilitation. The patient has remained under careful clinical supervision. The result of the patient's 1-year follow-up was satisfactory. CONCLUSIONS In this case, the endovascular approach was an effective, if temporary, option to open or hybrid surgery. This demonstrates that minimally invasive surgery can be helpful in some patients and can also be helpful as a bridge therapy. A good rapport between the surgeon and the patient is crucial to understanding the advantages and disadvantages of such treatment.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury

BACKGROUND

Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset.

STUDY DESIGN

Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients.

RESULTS

17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001).

CONCLUSIONS

TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.