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The limitations of thoracic endovascular aortic repair in altering the natural history of blunt aortic injury

Jennifer L Lang, Joseph P Minei, J Gregory Modrall, G Patrick Clagett, R James Valentine
Journal of Vascular Surgery 2010, 52 (2): 290-7; discussion 297
20471772

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is accepted treatment for blunt aortic injury (BAI). We hypothesized that immediate TEVAR would reduce deaths from aortic rupture in patients with BAI.

METHODS: Review of 81 patients with BAI who arrived alive at a level I trauma center over a 10-year period.

RESULTS: Twenty-three patients (28%) died within 4 hours of admission, including 12 who died of aortic rupture. Fifty-eight patients (72%) survived beyond 4 hours, and 8 (14%) ultimately died of associated injuries. Forty patients (69%) underwent aortic repair (30 open repair, 10 TEVAR), and 2 died of multisystem organ failure (MSOF). Comparing open repair to TEVAR, there were no differences in the length of hospital stay (33 +/- 27 vs 33 +/- 31 days), operative complications (77% vs 70%), or mortality (7% vs 0). Ten patients (17%) with minimal BAI were treated with beta blockade and observation; 4 have not healed their aortic injuries and 6 have been lost to follow-up. Thirty-three of the original 81 study patients (41%) ultimately died. Compared with the patients who died, the survivors were younger (37 vs 48 years; P = .01) and less likely to develop aortic rupture (0 vs 12; P < .001), require intubation in the field (27% vs 49%; P < .05), require cardiopulmonary resuscitation (CPR; 2% vs 30%; P < .001), or arrive hypotensive (17% vs 67%; P < .001). Survivors also had a lower mean injury severity score (34 +/- 12 vs 44 +/- 12; P < .001), fewer associated injuries (3 +/- 1 vs 4 +/- 3; P = .02), and a higher prevalence of aortic repair (79% vs 6%; P < .001). Multivariate analysis selected no attempt at aortic repair (odds ratio [OR], 90.9; 95% confidence interval [CI], 10.6-1000) and hypotension on arrival (OR, 6.1; 95% CI, 1.4-27) as the only independent variables associated with death.

CONCLUSION: Mortality remains high for patients with BAI, but most patients who arrive alive at the hospital do not experience aortic rupture. Rupture occurs within the first 4 hours of admission, often before the injury is recognized in time for salvage with immediate TEVAR. The decision to repair BAI was based on the extent of associated injuries and on the individual surgeon's judgment. Survival was not influenced by the timing of repair, but further studies are needed to compare the outcome of open repair vs TEVAR in patients who survive beyond 4 hours.

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