Late outcomes following open and endovascular repair of blunt thoracic aortic injury

Himanshu J Patel, Mark R Hemmila, David M Williams, Amy C Diener, G Michael Deeb
Journal of Vascular Surgery 2011, 53 (3): 615-20; discussion 621

BACKGROUND: Previous studies have focused on early outcomes of open (descending thoracic aortic repair [DTAR]) and endovascular (thoracic endovascular aneurysm repair [TEVAR]) repair of blunt aortic injury (blunt thoracic aortic injury [BTAI]). Late results remain ill-defined and are the focus of this study.

METHODS: One hundred nine patients (1992-2010) underwent repair for BTAI. Mean age was 39.0 years (73.4% male). DTAR was performed in 90, with left heart bypass (85) or hypothermic arrest (5). TEVAR was used in 19 of 45 patients treated since 2002. A strategy of selective delayed repair has been used since 1997, with 54 of 75 patients treated with delayed repair in this interval. The primary outcome was vital status (100% follow-up; mean, 103.9 months).

RESULTS: Mean Injury Severity Score was 39.5. Thirty-day mortality was 4.6% (n = 5). Early morbidity included permanent spinal cord ischemia (SCI, 1.8%), stroke (2.8%), and need for permanent dialysis (1.8%). Independent predictors of a composite outcome of early mortality and these morbidities included age >60 years (odds ratio [OR], 8.4; P = .015), increasing preoperative creatinine (OR, 7.9; P = .017), and occurrence of postoperative sepsis (OR, 9.6; P = .021). Fifteen-year Kaplan-Meier survival was 81.3%. Independent predictors of late mortality included age >60 years (Cox hazard ratio [HR], 4.1; P = .01), increasing creatinine (HR, 9.1; P < .001), or occurrence of postoperative SCI (HR, 20.6; P < .001), but not repair type (P = .73). Endograft collapse occurred in one patient, necessitating reintervention. Freedom from aortic reintervention at 4 years was higher after open repair (DTAR 100% vs TEVAR 94%; P = .03).

CONCLUSIONS: With careful selection, open or endovascular repair of BTAI has excellent early and late results. Although TEVAR has an increased risk for reintervention, factors other than treatment strategy impact late survival. These data support the growing role of an endoluminal approach for BTAI in anatomically appropriate patients.

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