Progress in the treatment of blunt thoracic aortic injury: 12-year single-institution experience

Anthony L Estrera, David C Gochnour, Ali Azizzadeh, Charles C Miller, Sheila Coogan, Kristofer Charlton-Ouw, John B Holcomb, Hazim J Safi
Annals of Thoracic Surgery 2010, 90 (1): 64-71

BACKGROUND: Recent advancements in the diagnosis and management of blunt thoracic aortic injury have improved outcomes after operative repair. With consideration of these advancements, we analyzed our level 1 trauma experience with blunt traumatic aortic injury.

METHODS: Between January 1997 and March 2009, 255 patients with blunt traumatic aortic injury were entered into the Utah Trauma Registry-Trauma Center Registry. Of these, 145 (58%) patients underwent thoracic aortic repair, with 12 (5%) undergoing aortic exploration without repair. Median age was 32 years (range, 13 to 87), with 43 (30%) women. Repair approach included open repair without adjunct (clamp), open with distal aortic perfusion, open with cardiopulmonary bypass, and thoracic endovascular aortic repair. The affect of management modifications, which included use of distal aortic perfusion (1999), delayed repair (2002), and use of thoracic endovascular aortic repair (2005) was analyzed. We used multiple logistic regression to evaluate the changes in morbidity (paraplegia and stroke) and mortality attributable to changes in surgical practice, adjusted for calendar time and injury severity score.

RESULTS: Mortality from operative aortic intervention for blunt thoracic aortic injury (BTAI) was 17% (24 of 145). Delayed repair, used in 41% (59 of 145) of repairs, was associated with only 1 death (2%), which was significantly lower than immediate repair 28% (23 of 86) mortality (p < 0.002). Mean injury severity score was 39 +/- 11. Adjusted for injury severity score and calendar time, delayed repair resulted in a greater than tenfold reduction in mortality compared with immediate open intervention (odds ratio 0.07, p < 0.02). Use of thoracic endovascular aortic repair was associated with zero mortality (p < 0.03 versus other treatments). Mortality with open repair with and without distal aortic perfusion was 14% and 31%, respectively, p < 0.02. Paraplegia occurred in 10% with open repair without distal aortic perfusion, and in no cases in open with distal aortic perfusion and thoracic endovascular aortic repair.

CONCLUSIONS: Although thoracic aortic injury still accounts for significant mortality during blunt trauma, patients reaching specialized trauma centers can achieve good results with thoracic aortic repair. Improved early outcomes have been observed with delayed selective management and thoracic endovascular repair. Long-term results of thoracic endovascular aortic repair, however, need further study.

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