Acute blunt traumatic injury to the descending thoracic aorta

Paul J Riesenman, James D Brooks, Mark A Farber
Journal of Vascular Surgery 2012, 56 (5): 1274-80

INTRODUCTION: Blunt injury to the descending thoracic aorta is a potentially life-threatening condition necessitating rapid assessment and possible surgical intervention. The purpose of this study was to review outcomes of patients who sustained blunt thoracic aortic injury at a single institution.

METHODS: Our institutional Trauma Registry Database was searched for patients who sustained acute blunt descending thoracic aortic injury between July 1990 and July 2010. Individual injuries, anatomic and physiological measures of injury severity, and operative and hospital mortality were compared between patients undergoing open surgical and thoracic endovascular aortic repair. Additionally, aortic injury grade, management, and outcomes were reviewed for patients who did not undergo an aortic intervention.

RESULTS: Of the 100 patients identified over the 20-year study period, 60 (60%) underwent conventional open repair, 26 (26%) underwent endovascular repair, and 14 (14%) did not undergo an aortic intervention. The overall hospital mortality rate for the entire patient cohort was 34%. Of the 14 patients who did not undergo an aortic intervention, five (36%) were successfully medically managed and four (80%) of these had grade I aortic injuries. One of the successfully medically managed patients required endovascular repair 9 months after injury. Four medically managed patients expired as a result of aortic rupture within 1 to 2.5 hours of presentation. Two expired immediately after diagnosis, and the other two could have potentially been treated with improvements in transfer and diagnosis times. Age, individual injuries, and measures of injury severity were similar between patients undergoing open surgical or endovascular repair. Patients who underwent endovascular repair experienced a significantly lower intraoperative (0% vs 18%; P < .05) and overall hospital mortality (12% vs 37%; P < .05). Additionally, endovascular repair was associated with reductions in operative time, estimated blood loss, and intraoperative blood transfusions. Five endovascular patients required secondary interventions to treat endograft-related complications, including malapposition to the aortic arch (n = 3), midendograft stenosis (n = 1), and left upper extremity ischemia (n = 1).

CONCLUSIONS: Blunt thoracic aortic injury to the descending thoracic aorta is associated with a high overall hospital mortality. Thoracic endovascular aortic repair is associated with significantly lower operative times, procedural blood loss, intraoperative blood transfusion, as well as intraoperative and overall hospital mortality compared with conventional open surgical repair. Consideration of this form of therapy as the initial form of treatment is warranted in anatomically acceptable candidates.

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