Blunt thoracic aortic injury: delayed or early repair?

OBJECTIVE: To evaluate the safety and benefit of delayed repair of blunt thoracic aortic injury (BTAI) in trauma patients with multiple injuries and to assess the financial impact of delayed repair.

METHODS: A retrospective review of charts was performed on 55 patients with the diagnosis of BTAI from January 1, 1992, through December 31, 1997, at our Level I trauma center. Early repair was defined as operative repair of BTAI within 12 hours of admission. Seven patients were excluded from analysis due to death before BTAI diagnosis (two deaths were from rupture in the emergency department and five were from massive blunt trauma without rupture). The groups were compared by using a McNemar chi2 test, for which p less than or equal to 0.05 is significant.

RESULTS: There were 30 patients in the early repair (ER) group repaired at 5.3+/-2.4 hours, and 18 patients in the delayed repair (DR) group repaired at 8.5 days (range, 17 hours-67 days). There were no significant differences between the ER and DR groups in age (37+/-18 years vs. 41+/-19 years), Injury Severity Score (39+/-15 vs. 45+/-14), intensive care unit days (12+/-14 days vs. 18+/-11 days), hospital length of stay (21+/-19 days vs. 28+/-14 days), or mortality rates (7% vs. 6%). There was a trend toward longer lengths of stay in the DR group. Most DR patients required beta-blocker therapy and/or other antihypertensives for systolic BP more than 120 mm Hg during admission. There were no deaths from aortic rupture in either group. By using financial data that was available from July of 1994 onward, we performed a subset analysis of the direct costs associated with BTAI. Total direct and variable direct costs for patients undergoing delayed repair were over two times the costs for early repair patients (p < 0.05).

CONCLUSION: The management of trauma patients with multiple injuries requires prioritization of injuries so that the outcomes from these injuries can be optimized. Although delayed aortic repair was safely practiced in this series, there was not an obvious outcome benefit to delayed repair. The patients undergoing late repair required increased attention to hemodynamics, and there was a trend toward increased length of stay. In addition, analysis of the costs associated with delayed repair demonstrated a twofold increase in the direct costs for delayed repair compared with early repair.